1.7 Treatment of Substance Use Disorders
Open Resources for Nursing (Open RN)
Research has shown that substance use disorders are similar in course, management, and outcome to other chronic illnesses, such as hypertension, diabetes, and asthma. It is possible to adopt the same type of chronic care management approach to the treatment of substance use disorders as is used to manage chronic physical illnesses. Remission of substance use disorders and even full recovery can be achieved if evidence-based care is provided for adequate periods of time by properly trained health care professionals and augmented with supportive monitoring, recovery support services, and social services.[1]
There are a spectrum of effective strategies and services available to identify, treat, and manage substance use disorders. Research shows that the most effective way to help someone with a substance misuse problem who is at risk for developing a substance use disorder is to intervene early, before the condition can progress. Screening for substance misuse is increasingly being provided in general health care settings so that emerging problems can be detected and early intervention provided. The addition of services to address substance use problems and disorders in mainstream health care has extended the continuum of care and includes a range of effective, evidence-based medications; behavioral therapies; and supportive services. However, a number of barriers have limited the widespread adoption of these services, including common myths about addiction, lack of resources, insufficient training, and workforce shortages. This is particularly true for the treatment of individuals with co-occurring substance use and mental health disorders.[2]
There are several common myths about addiction that make it harder for people with substance use disorders to seek treatment to get well. Review these myths in the following box.
Common Myths About Addiction[3]
- Using drugs or alcohol is a choice, so if someone gets addicted, it’s their fault.
- Reality: Addiction is a consequence of many contributing factors, including genetics, neurobiology, adverse childhood effects (ACEs), trauma, and other influences.
- If someone just uses willpower, they should be able to stop using the substance.
- Reality: For people who are genetically vulnerable to addiction, substance uses can cause profound changes in the brain that hijack the reward pathway of the brain. Addictive substances flood the brain with neurotransmitters than signal pleasure. These changes create intense impulses to continue using the substances despite negative consequences of doing so.
- Addiction affects certain types of people.
- Reality: Addiction can affect anyone, no matter one’s age, income, ethnicity, religion, family, or profession. Nationally, about one in eight people ages 12 and older are impacted.
- If someone has a stable job and family life, they can’t be suffering from addiction.
- Reality: Anyone is vulnerable to addiction. Many people hide the severity of their illness or don’t get help because of stigma or shame.
- People have to become seriously ill before they can get well.
- Reality: The longer a person waits to get help, the more changes happen to the brain, which can have deadly consequences like overdose. Studies show that people forced into treatment have an equal chance of successful recovery as people who initiate treatment on their own.
- Going to rehab will fix the problem.
- Reality: Addiction is a chronic disease, similar to hypertension or diabetes, that can be controlled but not cured. Treatment is the first step towards wellness, but it is just the beginning. Staying well requires a lifelong commitment to managing the chronic disease.
- If someone relapses, they can never get better.
- Reality: Relapse is no more likely with addiction than other chronic illnesses like diabetes. Getting well involves changing deeply embedded behaviors that are significantly rewarded in the brain. Behavioral change takes time and effort, and setbacks can occur. A relapse can signal that the treatment approach or other supports need to change or that other treatment methods are needed. There is hope that people who experience a relapse will return to recovery.
Substance use disorder treatment is designed to help individuals stop or reduce harmful substance misuse, improve their health and social function, and manage their risk for relapse. For example, mild substance use disorders can be identified quickly in many medical settings and often respond to brief motivational interventions and/or supportive monitoring, referred to as guided self-change. In contrast, severe and chronic substance use disorders often require specialty substance use disorder treatment and continued post-treatment support to achieve full remission and recovery. To address the spectrum of problems associated with substance use disorders, a continuum of care is planned and implemented based on an individual’s needs, including early intervention, treatment, and recovery support services.[4]
Early Intervention
Early intervention services can be provided in a variety of settings (e.g., school clinics, primary care offices, mental health clinics) to people who have substance misuse problems or mild substance use disorders. These services are usually provided when an individual presents for another medical condition or social service need and is not necessarily seeking treatment for a substance use disorder. The goals of early intervention are to reduce the harms associated with substance misuse, reduce risk behaviors before they lead to injury, improve health and social function, and prevent progression from misuse to a substance use disorder. Early intervention consists of providing education about risks of substance use, safe levels of alcohol and medication use, and strategies to quit substance use. Referral to treatment services is provided as needed.[5]
Populations Who Should Receive Early Intervention
Early intervention should be provided to children, adolescents, and adults who show signs of substance misuse or a mild substance use disorder. One group in need of early intervention is people who binge drink, particularly those aged 12 to 17, who are at higher risk for future substance use disorders because of their young age. 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 routine medical care can educate and motivate many individuals who are misusing substances to understand and acknowledge their risky behavior and reduce their substance use.[6]
Regardless of the substance, the first step of early intervention is using a screening tool to identify behaviors that put the individual at risk for harm or for developing a substance use disorder. Positive screening results should be followed by brief educational sessions tailored to the specific problems and interests of the individual. It should be delivered in a nonjudgmental manner, emphasizing both the importance of reducing substance use and the individual’s ability to accomplish this goal. Follow-up evaluation should assess whether the screening and the brief intervention were effective in reducing the substance misuse or if formal treatment is required.[7]
Components of Early Intervention
One structured approach to delivering early intervention to people showing signs of substance misuse and/or early signs of a substance use disorder is through screening and brief intervention (SBI). Research has shown that several methods of SBI are effective in decreasing substance misuse for a variety of populations in a variety of health care settings.
Screening
Ideally, substance misuse screening should occur for all individuals who present to health care settings, including primary care, urgent care, mental health care, and emergency departments. Several validated screening instruments have been developed to help nonspecialty providers identify individuals who may have, or be at risk for, a substance use disorder. An example of an evidence-based screening tool is the Alcohol Use Disorders Identification Test (AUDIT).[8] Based on a World Health Organization study, the AUDIT has become the world’s most widely used alcohol screening instrument and is available in approximately 40 languages. It is a self-administered questionnaire consisting of ten questions pertaining to an individual’s alcohol use. Read additional details about the AUDIT tool in the following box.
AUDIT Screening Tool
Review the full AUDIT tool: Check Your Drinking: An Interactive self-test.
The screening tool includes ten questions with answers ranging from 0 (Never) to 4 (4 or more times a week):
- How often do you have a drink containing alcohol?
- How many standard drinks containing alcohol do you have on a typical day when drinking?
- How often do you have six or more drinks on one occasion?
- During the past year, how often have you found that you were not able to stop drinking once you had started?
- During the past year, how often have you failed to do what was normally expected of you because of drinking?
- During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?
- During the past year, how often have you had a feeling of guilt or remorse after drinking?
- During the past year, how often have you been unable to remember what happened the night before because you had been drinking?
- Have you or someone else been injured as a result of your drinking?
- Has a relative, friend, doctor, or other health worker been concerned about your drinking or suggested you cut down?
Brief Interventions
Brief interventions is a term used to describe quick therapeutic techniques used to initiate change in individuals with unhealthy behaviors. For example, motivational interviewing (MI) is a client-centered therapeutic technique that can be used to address a person’s ambivalence to change their use of substances. It uses a conversational approach to help the client discover their interest in changing their behavior. The nurse asks the client to express their desire for change and any ambivalence they might have and then begins to work with the client on making a plan to change their behavior and a commitment to the change process. Individuals who receive MI are more likely to adhere to a treatment plan and subsequently achieve better outcomes.[9]
Referral
When an individual’s substance use problem meets criteria for a substance use disorder or when brief interventions do not produce change, referral to specialized treatment should occur. This is called Screening, Brief Intervention, and Referral to Treatment (SBIRT). A referral for assessment and development of a clinical treatment plan is created with the client and tailored to meet their needs. Effective referral processes should incorporate strategies to motivate the client to accept the referral and assistance in navigating barriers for treatment.[10]
Compare the effectiveness of communication with a client being treated in the emergency department for injuries sustained when driving under the influence of alcohol in these YouTube videos:
Video 1[11]: Anti-SBIRT (Doctor A)
Video 2 (Using SBIRT)[12]: Using SBIRT Effectively (Doctor B)
Treatment
Treatment can occur in a variety of settings, but treatment for severe substance use disorders has traditionally been provided in specialty substance use disorder treatment programs. The National Institute on Drug Abuse (NIDA) outlines the following evidence-based principles for effective treatment of adults and adolescents with substance use disorders[13]:
Addiction is a complex but treatable disease that affects brain function and behavior. Psychoactive substances alter the brain’s structure and function, resulting in changes that persist long after substance use has ceased. This may explain why individuals with substance use disorder are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences of their behaviors.[14]
No single treatment is appropriate for everyone. Treatment varies depending on the type of drug and the characteristics of the individuals. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to their ultimate success in returning to productive functioning in the family, workplace, and society.[15]
Treatment must be readily available. Because individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential clients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.[16]
Effective treatment attends to multiple needs of the individual, not just their substance abuse. To be effective, treatment must address the individual’s substance abuse, as well as associated medical, psychological, social, vocational, and legal problems. It is also important that treatment is tailored to the individual’s age, gender, ethnicity, and culture.[17]
Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of the client’s problems and needs. Research indicates that most addicted individuals need at least three months in treatment to significantly reduce or stop their substance use and that the best outcomes occur with longer durations of treatment. Recovery from substance use disorder is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep clients in treatment.[18]
Behavioral therapies, including individual, family, or group counseling, are the most common types of treatment. Behavioral therapies vary in focus and may address a client’s motivation to change, provide incentives for abstinence, build skills to resist drug use, replace substance-using activities with constructive and rewarding activities, improve problem-solving skills, and facilitate interpersonal relationships. Additionally, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence.[19]
An individual’s treatment plan must be continually evaluated and modified as needed to ensure it meets their changing needs. A client may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, clients may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many clients, a recovery-oriented systems approach provides the best results, with the treatment intensity varying according to a person’s changing needs.[20]
Many individuals with substance use disorders also have other mental health disorders. Treatment should address all conditions using appropriate medications.[21]
Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions. Substance use during treatment must be monitored continuously because relapses during treatment do occur. Knowing their substance use is being monitored can be a powerful incentive for individuals to withstand urges to use substances. Monitoring also provides an early indication of a relapse, signaling an adjustment is needed in the individual’s treatment plan to better meet their needs.[22]
Treatment programs should test clients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction counseling. Many substance misuse-related behaviors put people at risk of infectious diseases. Targeted counseling reduces infectious disease. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can facilitate adherence to other medical treatments.[23]
Evidence-based treatment interventions include medications, behavioral therapies, and recovery services.[24]
Medications
Medications are an important element of treatment for many clients, especially when combined with counseling and other behavioral therapies. For example, methadone, buprenorphine, and naltrexone are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their substance misuse. Acamprosate, disulfiram, and naltrexone are medications approved for treating alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (available as patches, gum, lozenges, or nasal spray) or an oral medication (such as bupropion or varenicline) can be an effective component of treatment when part of a comprehensive behavioral treatment program.[25] See Table 14.7 for a list of medications approved by the FDA to treat alcohol and opioid use disorders.
Table 14.7 Pharmacotherapy to Treat Alcohol and Opioid Use Disorders[26]
| Medication | Use | DEA Schedule | Application |
|---|---|---|---|
| Buprenorphine-naloxone | Opioid use disorder | CIII | Used for detoxification or maintenance of abstinence. |
| Methadone | Opioid use disorder | CII | Used for withdrawal and long-term maintenance of abstinence of opioid addiction. Dispersed only at opioid treatment centers certified by SAMHSA and approved by state authority. |
| Naltrexone | Opioid use disorder and alcohol use disorder | Not scheduled under the Controlled Substances Act | Block opioid receptors, reduce cravings, and diminish rewarding effects of opioids and alcohol. Extended-release injections are recommended to prevent relapse. |
| Acamprosate | Alcohol use disorder | Not scheduled under the Controlled Substances Act | Used for maintenance of alcohol abstinence. |
| Disulfiram | Alcohol use disorder | Not scheduled under the Controlled Substances Act | Causes severe physical reactions when alcohol is ingested, such as nausea, flushing, and heart palpitations. The knowledge that the reaction will occur acts as a deterrent to drinking alcohol. |
Medically assisted detoxification is only the first stage of treatment and by itself does little to change long-term substance misuse. Although medically assisted detoxification can safely manage the acute physical symptoms of withdrawal, detoxification alone is rarely sufficient to help individuals achieve long-term abstinence of substances. Clients should be encouraged to continue long-term treatment and recovery services following detoxification.[27]
Behavioral Therapies
In addition to medications, effective treatment of SUD includes behavioral therapies to help clients recognize the impact of substance misuse on their interpersonal relationships and ability to function in a healthy, safe, and productive manner. Behavioral therapies also teach and motivate clients to change their behaviors as a way to control their substance use disorders.[28] Evidence-based behavioral therapies include cognitive-behavioral therapy, dialectical behavior therapy, family therapy, contingency management, community reinforcement approach, motivational enhancement therapy, matrix model, and twelve-step facilitation. These therapies are further described in the following subsections.
Cognitive-Behavioral Therapy
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. As a result, CBT treatments involve techniques to modify such behaviors and improve coping skills by emphasizing the identification and modification of dysfunctional thinking. CBT is a short-term approach, usually involving 12 to 24 weekly individual sessions. These sessions typically explore the positive and negative consequences of substance use with self-monitoring as a mechanism to recognize cravings and other situations that may lead the individual to relapse. They also help the individual develop healthy coping strategies.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is an evidence-based therapy that teaches a skill called mindfulness. Multiple research studies have noted that mindfulness is potentially useful in helping people diagnosed with SUD gain mastery over substance cravings.[29]
Family Therapy
Family behavior therapy (FBT) is a therapeutic approach used for both adolescents and adults that addresses not only substance use but also other issues the family may be experiencing, such as mental health disorders and family conflict. FBT includes up to 20 treatment sessions that focus on developing skills and setting behavioral goals. Basic necessities are reviewed and inventoried with the client, and the family pursues resolution strategies and addresses activities of daily living, including violence prevention and HIV/AIDS prevention.[30]
Contingency Management
Behavior change involves learning new behaviors and changing old behaviors. Positive rewards or incentives for changing behavior can aid this process. Contingency management involves giving tangible rewards to individuals to support positive behavior change and has been found to effectively treat substance use disorders. In this therapy clients receive a voucher with monetary value that can be exchanged for food items, healthy recreational options (e.g., movies), or other sought-after goods or services when they exhibit desired behavior such as drug-free urine tests or participation in treatment activities. Clinical studies comparing voucher-based reinforcement to traditional treatment regimens have found that voucher-based reinforcement is associated with longer treatment engagement, longer periods of abstinence, and greater improvements in personal function. These positive findings, initially demonstrated with individuals with cocaine use disorders, have been reproduced in individuals with alcohol, opioid, and methamphetamine use disorders.[31]
Community Reinforcement Approach
Community reinforcement approach (CRA) plus vouchers is an intensive 24-week outpatient program that uses incentives and reinforcers to reward individuals who reduce their substance use. Individuals are required to attend one to two counseling sessions each week that emphasize improving relations, acquiring skills to minimize substance use, and reconstructing social activities and networks to support recovery. Individuals receiving this treatment are eligible to receive vouchers with monetary value if they provide drug-free urine tests several times per week. Research has demonstrated that CRA plus vouchers promotes treatment engagement and facilitates abstinence.[32]
Motivational Enhancement Therapy
Motivational enhancement therapy (MET) uses motivational interviewing techniques to help individuals resolve any uncertainties they have about stopping their substance use. MET works by promoting empathy, developing client awareness of the discrepancy between their goals and their unhealthy behavior, avoiding argument and confrontation, addressing resistance, and supporting self-efficacy to encourage motivation and change. The therapist supports the client in executing the behaviors necessary for change and monitors progress toward client-expressed goals.[33]
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. The model consists of 16 weeks of group sessions held three times per week, which combine CBT, family education, social support, individual counseling, and urine drug testing.[34]
Twelve-Step Facilitation
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 12-step programs.[35] Twelve-step programs are further discussed under the “Recovery Support Services” section below.
TSF focuses on three key ideas:
- 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 12-step program
- Active involvement in a 12-step program
Recovery Support Services
In addition to medications and behavioral therapies, effective treatment of SUD includes recovery support services (RSS). Recovery support services provided by substance use disorder treatment programs and community organizations provide support to individuals receiving treatment for SUD, as well as ongoing support after treatment. These supportive services are typically delivered by trained case managers, recovery coaches, and/or peers. Specific RSS include assistance in 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. RSS can be effective in promoting healthy lifestyle techniques to increase resilience skills, reduce the risk of relapse, and help achieve and maintain recovery. Individuals who participate in RSS typically have better long-term recovery outcomes.[36]
Recovery goes beyond abstinence and the remission of substance use disorder to include a positive change in the whole person. There are many paths to recovery. People choose their individual pathway based on their cultural values, socioeconomic status, psychological and behavioral needs, and the nature of their substance use disorder.[37]
A study of over 9,000 individuals with previous substance use disorders asked how they defined recovery. These three themes emerged[38]:
- Abstinence: 86 percent viewed abstinence as part of their recovery, but the remainder did not think abstinence was important for their recovery. However, abstinence was considered “essential” by those affiliated with 12-step mutual aid groups.
- Personal growth: “Being honest with myself” was endorsed as part of recovery by 98 percent of participants. Other almost universally endorsed elements included “handling negative feelings without using alcohol or drugs” and “being able to enjoy life without alcohol or drugs.” Almost all study participants viewed their recovery as a process of growth and development, and about two thirds saw it as having a spiritual dimension.
- Service to others: Engaging in service to others was another prominent component of how study participants defined recovery. This is perhaps because during periods of heavy substance misuse, individuals may damage interpersonal relationships, which they later regret and attempt to resolve during recovery. Service to others has evidence of helping individuals maintain their own recovery.[39]
Recovery-Oriented Systems of Care (ROSC) embrace the idea that severe substance use disorders are most effectively addressed through a chronic care management model that includes long-term, outpatient care, recovery housing, and recovery coaching and management checkups. ROSC are designed to be easy to navigate for people seeking help, transparent in their operations, and responsive to the cultural diversity of the communities they serve. ROSC often use long-term recovery management protocols, such as recovery management checkups and telephone case monitoring.[40]
Even when remission is achieved after one or two years, it can take four to five more years before an individual’s risk of relapse drops below 15 percent (the level of risk that people in the general population have of developing a substance use disorder in their lifetime). As a result, similar to other chronic illnesses, a person with a serious substance use disorder often requires ongoing monitoring and management to maintain remission and to provide early reintervention should relapse occur. Recovery support services (RSS) refer to the collection of community services that can provide emotional and practical support for continuing remission, as well as daily structure and rewarding alternatives to substance use. Recovery supports include services such as mutual aid groups, recovery coaches, recovery housing, community care, and education-based recovery support.
Mutual Aid Groups
Mutual aid groups, such as 12-step groups, are well-known recovery supports, and they share a number of features. Members share their substance use problem and value learning from each other’s experiences as they focus on personal-change goals. The groups are voluntary associations that charge no fees and are member-led.
Alcoholics Anonymous
Alcoholics Anonymous (AA) has been in existence since 1935. Its philosophy, approach, and format have been adapted by groups focusing on recovery from other substances, such as Narcotic Anonymous, Cocaine Anonymous, Marijuana Anonymous, and Crystal Meth Anonymous. AA and derivative programs share two major components: social fellowship and a 12-step program of action that was formulated based on members’ experiences of recovery from severe alcohol use disorders. These 12 steps are ordered in a logical progression, beginning with accepting that one cannot control one’s substance use, followed by abstaining from substances permanently, and transforming one’s spiritual outlook, character, and relationships with other people.[41]
Research studying 12-step mutual aid groups, specifically those focused on alcohol, has shown that participation in the groups promotes an individual’s recovery by strengthening recovery-supportive social networks; increasing members’ abilities to cope with risky social contexts and negative emotions; augmenting motivation to recover; reducing depression, craving, and impulsivity; and enhancing psychological and spiritual well-being.[42]
Find a local Alcoholics Anonymous group near you: Find A.A. Near You
Al-Anon and Alateen
Friends and family members often suffer when a loved one has a substance use disorder. This can include worrying about their loved one experiencing accidents, injuries, legal consequences, diseases, or death or experiencing verbal or physical abuse. Mutual aid groups provide emotional support to concerned significant others to help them systematically and strategically cope with the problems related to the substance misuse of their loved one.[43]
Al-Anon is a mutual aid group for family members dealing with substance misuse in a loved one. Like AA, Al-Anon is based on a 12-step philosophy and provides support whether or not members’ loved ones seek help or achieve remission or recovery. More than 80 percent of Al-Anon members are women. The principal goal of Al-Anon is to foster emotional stability and “loving detachment” from the loved one rather than coaching members to “get their loved one into treatment or recovery.” Al-Anon includes Alateen that focuses on the specific needs of adolescents affected by a parent’s or other family member’s substance use. Research studies regarding the effectiveness of Al-Anon show that participating family members experience reduced depression, anger, and relationship unhappiness at rates comparable to those of individuals receiving psychological therapies.[44]
Find a local Al-Anon group near you: Al-Anon Meetings
Recovery Coaches
Voluntary and paid recovery coaches help individuals discharging from treatment to connect to community services while addressing any barriers or problems that may hinder the recovery process. A recovery coach’s responsibilities may include providing strategies to maintain abstinence, connecting people to recovery housing and social services, and helping people develop personal skills that maintain recovery.[45]
Recovery Housing
Recovery-supportive houses provide both a substance-free environment and mutual support from fellow recovering residents. Many residents stay in recovery housing during or after outpatient treatment, with self-determined residency lasting for several months to years. Residents often informally share resources and give advice based on their experience in accessing health care, finding employment, managing legal problems, and interacting with the social service system.[46]
Community Care
Recovery community centers may host mutual aid group meetings; offer recovery coaching, education, and social events; and provide access to other resources such as housing, education, and employment. Some recovery community centers encourage community members to engage in advocacy to combat negative public attitudes, educate the community, and improve supports for recovery in the community.[47]
Education-Based Recovery Support
Education-based recovery support services are designed to help individuals in early substance use disorder recovery achieve their educational goals while also focusing on the areas of their social, emotional, spiritual, and physical well-being needed to help sustain recovery. High school and college environments can be difficult for students in recovery because of high levels of substance misuse among other students, peer pressure to engage in substance use, and widespread availability of alcohol and drugs. High school and collegiate recovery support programs provide recovery-supportive environments and peer engagement with other students in recovery.[48]
Planning Individualized Treatment
After an individual is assessed and diagnosed with substance use disorder (SUD) by a trained professional based on criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a collaborative, personalized treatment plan is designed with the client to meet their specific needs. The treatment plan and goals should be person-centered and include strength-based approaches that draw upon an individual’s strengths and resources to keep them engaged in care. Individualized treatment plans should consider age, gender identity, race and ethnicity, language, health literacy, religion/spirituality, sexual orientation, culture, trauma history, and co-occurring physical and mental health problems. This increases the likelihood of successful treatment engagement and retention. Throughout treatment, individuals should be periodically reassessed to determine response to treatment and to make any needed adjustments to the treatment plan.[49]
Nurses can improve engagement and retention in treatment programs by building a strong therapeutic alliance with the client, effectively using evidence-based motivational strategies, acknowledging the client’s individualized barriers, and creating a positive environment. Referring individuals to recovery support services, such as child care, housing, and transportation, can also improve retention in treatment.[50]
Treatment Settings and Continuum of Care
The treatment of severe substance use disorder is typically delivered in freestanding programs in various settings (e.g., hospital, residential, or outpatient settings) that vary in the frequency of care delivery (e.g., daily sessions to monthly visits), range of treatment components offered, and planned duration of care. As clients 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 client self-management.[51]
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 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 clients whose current living situations are not conducive to recovery, outpatient services should be provided in conjunction with recovery-supportive housing. In general, clients with serious substance use disorders are recommended to stay engaged for at least one year in the treatment process, which may involve participating in three to four different programs or services at reduced levels of intensity, all of which are ideally designed to help the client prepare for continued self-management after treatment ends.[52]
The levels of the treatment continuum include the following:
- Medically monitored and managed inpatient care: An intensive service delivered in an acute, inpatient hospital setting. These programs are typically necessary for individuals who require withdrawal management, primary medical and nursing care, and for those with co-occurring mental and physical health conditions. Treatment is available 24 hours a day and usually provided by an interdisciplinary team of health care professionals who can address serious mental and physical health needs.
- Residential services: Organized services, also in a 24-hour setting but outside of a hospital. These programs typically provide support, structure, and an array of evidence-based clinical services. Such programs are appropriate for physically and emotionally stabilized individuals who may not have a living situation that supports recovery, may have a history of relapse, or have co-occurring physical and/or mental health illnesses.
- Partial hospitalization and intensive outpatient services: Services range from counseling and education to clinically intensive programming. Partial hospitalization programs are used as a step-down treatment option after completing residential treatment and are usually available 6 to 8 hours a day during the work week. These services are considered to be approximately as intensive but less restrictive than residential programs and are appropriate for clients living in an environment that supports recovery but who need structure to avoid relapse.
- Outpatient services: Group and individual behavioral interventions and medications when appropriate. These components of care can be offered during the day, before or after work or school, or in the evenings and weekends. 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. Outpatient programs are also suitable for individuals with concurrent mental health conditions.
Helping Individuals in Need of Treatment
Despite the fact that substance use disorders are widespread, only a small percentage of people receive treatment because of the barriers previously discussed. Results from the 2020 National Survey of Drug Use and Health (NSDUH) indicate that among people aged 12 or older in 2020, 14.9 percent (or 41.1 million people) needed substance use treatment in the past year (defined if they had a SUD diagnosed in the past year or if they received substance use treatment at a specialty facility in the past year). There are many common reasons people do not seek treatment[53]:
- Not ready to stop using (40.7 percent)
- Do not have health care coverage/could not afford (30.6 percent)
- Perceived negative effect on their job (16.4 percent) or cause neighbors/community to have a negative opinion (8.3 percent)
- Do not know where to go for treatment (12.6 percent) or no program has the type of treatment desired (11.0 percent)
- Do not have transportation, the programs are too far away, or hours are inconvenient (11.8 percent)
Nurses can use motivational interviewing strategies to explore clients’ reasons for not seeking treatment and address their perceived barriers to treatment.
Strategies to Reduce Harm
Strategies to reduce the harm associated with substance use have been developed to engage people in treatment, as well as address the needs of individuals who are not yet ready to participate in treatment. Harm reduction programs provide public health services to prevent and reduce substance use-related risks among those actively using substances. Strategies include outreach and education programs, needle/syringe exchange programs, overdose prevention education, and improving public access to naloxone to reverse potentially lethal opioid overdose. These strategies are designed to reduce negative consequences for people with substance use disorders and those around them, such as overdose and the transmission of HIV and other infectious diseases. They also encourage individuals to seek treatment to reduce, manage, and stop their substance use.[54]
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
- Face It Together. (n.d.) Common myths about addiction. https://www.wefaceittogether.org/learn/common-myths ↵
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
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- SBIRTInsitute. (2011, March 2). Anti-SBIRT (Doctor A). [Video]. YouTube. All rights reserved. https://youtu.be/ZGETDcFcAbI ↵
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- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
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- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
- Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵
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Quick therapeutic techniques used to initiate change in individuals with unhealthy behaviors.