Treatment & Recovery: Evidence-Based Approaches

By the end of this module, you will be able to:

• Describe the continuum of addiction treatment services
• Explain Medication-Assisted Treatment for different substances
• Compare CBT, motivational interviewing, and contingency management
• Discuss the evidence base for 12-step and other mutual support programs
• Apply principles of evidence-based prevention

Levels of Care

| Level | Setting | Intensity | Indication | |-------|---------|-----------|------------| | Early Intervention | Primary care, schools | Brief | At-risk use | | Outpatient | Office/clinic | 1-9 hrs/week | Mild-moderate SUD, stable | | Intensive Outpatient (IOP) | Clinic | 9-20 hrs/week | Moderate SUD, some stability | | Partial Hospitalization (PHP) | Hospital/clinic | 20+ hrs/week | Moderate-severe, need structure | | Residential | Treatment facility | 24/7 | Severe SUD, unstable environment | | Medically Managed Inpatient | Hospital | 24/7 medical | Medical withdrawal, comorbidities |

ASAM Criteria

The American Society of Addiction Medicine (ASAM) criteria guide level of care decisions based on six dimensions:

1. Acute intoxication/withdrawal potential
2. Biomedical conditions and complications
3. Emotional, behavioral, or cognitive conditions
4. Readiness to change
5. Relapse, continued use, or continued problem potential
6. Recovery/living environment

Alcohol Use Disorder

| Medication | Mechanism | Evidence | Notes | |------------|-----------|----------|-------| | Naltrexone | Opioid antagonist | Strong | Reduces craving, heavy drinking days | | Acamprosate | Glutamate modulation | Moderate | Maintains abstinence | | Disulfiram | Aldehyde dehydrogenase inhibitor | Moderate | Aversive reaction if drinking |

Naltrexone:

• Oral (daily) or injectable (monthly Vivitrol)
• Reduces reward from drinking
• Evidence strongest for reducing heavy drinking days
• Can use with goal of moderation or abstinence

Acamprosate:

• Three times daily dosing
• Best evidence for maintaining abstinence
• Works on glutamate/GABA balance
• Safe in liver disease

Disulfiram (Antabuse):

• Creates unpleasant reaction if alcohol consumed
• Nausea, flushing, headache, palpitations
• Requires high motivation, supervised administration
• Risk of severe reaction

Opioid Use Disorder

| Medication | Mechanism | Setting | Evidence | |------------|-----------|---------|----------| | Buprenorphine | Partial agonist | Office-based | Very strong | | Methadone | Full agonist | OTP only | Very strong | | Naltrexone | Antagonist | Any | Strong |

Buprenorphine (Suboxone, Subutex):

• Partial agonist at mu-receptor
• Ceiling effect limits overdose risk
• Office-based treatment possible
• Reduces mortality 50%+

Methadone:

• Full agonist, long half-life
• Requires daily dispensing at licensed clinic initially
• Most effective for high-dose opioid users
• Also reduces mortality 50%+

Naltrexone (Vivitrol):

• Monthly injection blocks opioid effects
• Requires completed detox (7-14 days opioid-free)
• Good for highly motivated patients
• Risk of overdose if relapse (lost tolerance)

Tobacco Use Disorder

| Treatment | Efficacy | Notes | |-----------|----------|-------| | Varenicline | Highest | Partial agonist at nicotinic receptor | | Combination NRT | High | Patch + short-acting (gum/lozenge) | | Single NRT | Moderate | Patch, gum, lozenge, inhaler, spray | | Bupropion | Moderate | Also treats depression |

Stimulant Use Disorder

No FDA-approved medications

Under investigation:

• Mirtazapine
• Bupropion + naltrexone
• N-acetylcysteine
• Topiramate

Behavioral treatments remain primary approach.

Cognitive Behavioral Therapy (CBT)

Core Principles:

• Thoughts, feelings, and behaviors are interconnected
• Maladaptive thought patterns drive substance use
• Skills can be learned to change patterns
• Focus on current problems, practical strategies

Key Components:

1. Functional Analysis: Identify triggers, thoughts, feelings leading to use
2. Skills Training: Coping with craving, refusal skills, problem-solving
3. Cognitive Restructuring: Challenge distorted thinking
4. Relapse Prevention: Identify high-risk situations, develop plans

Evidence: Strong evidence across substances; effects maintained post-treatment.

Motivational Interviewing (MI)

Core Principles:

• Ambivalence about change is normal
• Motivation is elicited, not imposed
• Patient is the expert on their own life
• Resistance is a signal to change approach

OARS Skills:

• Open questions: Encourage elaboration
• Affirmations: Recognize strengths
• Reflections: Demonstrate understanding
• Summaries: Link ideas together

The Spirit of MI:

• Partnership (collaboration, not hierarchy)
• Acceptance (autonomy, worth, empathy, affirmation)
• Compassion (prioritize patient welfare)
• Evocation (draw out patient's own motivations)

Evidence: Effective across substances; particularly useful for ambivalent patients.

Contingency Management (CM)

Core Principle: Provide tangible rewards for objectively verified positive behaviors (negative drug tests, treatment attendance).

Implementation:

• Frequent monitoring (e.g., twice-weekly urine tests)
• Immediate rewards for negative tests
• Escalating value for consecutive negatives
• Reset after positive test

Evidence: Strongest evidence for stimulant use disorders; effective across substances.

Challenges:

• Funding for incentives
• Administrative burden
• "Paying people not to use drugs" criticism

Community Reinforcement Approach (CRA)

Core Principle: Make a sober lifestyle more rewarding than substance use.

Components:

• Functional analysis
• Sobriety sampling (trial period of abstinence)
• Treatment plan with goals
• Social/recreational counseling
• Job-finding training
• Relationship counseling
• Relapse prevention

Often Combined With: Contingency management (CRA + Vouchers)

Overview

Alcoholics Anonymous (AA) founded 1935; model adapted for other substances:

• Narcotics Anonymous (NA)
• Cocaine Anonymous (CA)
• Gamblers Anonymous (GA)
• And many others

The 12 Steps (summarized):

1. Admitted powerlessness over addiction
2. Came to believe a higher power could restore sanity
3. Made decision to turn will over to higher power
4. Made a searching moral inventory
5. Admitted wrongs to God, self, and another person 6-7. Became ready for and asked God to remove shortcomings 8-9. Made list of those harmed and made amends
6. Continued personal inventory
7. Sought through prayer/meditation to improve conscious contact
8. Having had spiritual awakening, carry message to others

Evidence Base

Research Findings:

• AA attendance associated with better outcomes
• Effects mediated by increased self-efficacy, social support, coping
• Manualized Twelve-Step Facilitation (TSF) tested in Project MATCH
• TSF as effective as CBT and MET for alcohol

Cochrane Review (2020):

• AA/TSF produces higher rates of continuous abstinence
• Effects comparable or superior to other treatments for abstinence

Considerations

Strengths:

• Free and widely available
• Peer support
• Structured program
• Lifelong access

Limitations/Concerns:

• Spiritual component not for everyone
• "Powerlessness" concept criticized
• Abstinence-only focus
• Self-selection in studies
• May not suit all cultures

Alternatives to 12-Step

• SMART Recovery: CBT-based, secular
• Refuge Recovery/Recovery Dharma: Buddhist-based
• LifeRing: Secular, self-empowerment focus
• Women for Sobriety: Women-specific
• Moderation Management: For non-dependent problem drinkers

Prevention Levels Reviewed

| Level | Target | Examples | |-------|--------|----------| | Universal | Entire population | School programs, media campaigns, policy | | Selective | At-risk groups | Children of addicted parents, trauma survivors | | Indicated | Early symptoms | Brief interventions for risky use |

What Works in Prevention

Effective:

• Raising alcohol taxes
• Raising minimum drinking age
• Brief interventions in healthcare settings
• Family-based programs (Strengthening Families)
• Life skills training in schools
• Community-level interventions

Ineffective:

• Fear-based approaches ("Just Say No")
• Information-only education
• One-time assemblies
• DARE program (no effect on use)

SBIRT Model

Screening, Brief Intervention, and Referral to Treatment:

1. Screening: Universal screening with validated tools (AUDIT, DAST)
2. Brief Intervention: For at-risk users—feedback, advice, goal-setting
3. Referral to Treatment: For those meeting SUD criteria

Evidence: Cost-effective, reduces risky drinking, increases treatment entry.

Recovery Capital

Definition: The sum of resources necessary to initiate and sustain recovery.

Domains:

• Social: Relationships, support networks
• Physical: Health, safe housing, finances
• Human: Skills, education, employment
• Cultural: Values, beliefs, identity
• Community: Recovery community, resources

Recovery-Oriented Systems of Care

Modern approach recognizes:

• Recovery is a process, not an event
• Multiple pathways to recovery
• Services should be person-centered
• Peer support is valuable
• Recovery is supported by addressing social determinants

Peer Support Services

Peer Recovery Support Specialists:

• Individuals in recovery providing support to others
• Lived experience as qualification
• Bridge between treatment and community
• Evidence for improved outcomes

• Treatment exists on a continuum from brief intervention to residential care
• MAT is first-line for opioid and alcohol use disorders, reducing mortality significantly
• CBT, MI, and CM are evidence-based behavioral treatments with different strengths
• 12-step programs have evidence for effectiveness; alternatives exist for those who prefer
• Fear-based prevention doesn't work; policy changes and skills training do
• Recovery is supported by building recovery capital across multiple domains
• Peer support services are increasingly recognized as valuable

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