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Chapter 7. Evolution in Addiction Treatment Concepts and Methods

A. Thomas McLellan, Ph.D.
DOI: 10.1176/appi.books.9781585623440.345610

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There has always been broad recognition that alcohol and drug abuse are partly or fully responsible for such serious public health and public safety problems as traffic accidents, street crime, transmission of infectious diseases, child abuse and neglect, and excessive use of medical services. During the 1970s, addiction treatments gained prominence as a social response to these addiction-related problems. This was because addiction treatments were less expensive than the available alternatives (e.g., jail or hospitalization) and because there was social compassion for the many addicted veterans of the Vietnam War whose substance use problems were seen as a result of that war.

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Table Reference Number

Addiction treatment is best considered as at least three separate stages—each with distinct goals and methods: 1) detoxification or stabilization is designed to eliminate the acute effects of substance use and prepare the patient for life change; 2) rehabilitation is designed to continue the initial abstinence and to help the patient develop a life that will be enjoyable without substances; and 3) continuing care follows formal treatment and consists of mutual help groups (usually Alcoholic Anonymous [AA]), professional therapy as needed, and often telephone monitoring calls designed to prevent relapse.

Within the rehabilitation and continuing care stages of treatment there is now an impressive array of treatment components that have shown U.S. Food and Drug Administration–level evidence of effectiveness.

Medications include naltrexone, buprenorphine, and methadone for opiate dependence; naltrexone, acamprosate, and disulfiram for alcohol dependence; and disulfiram for cocaine dependence.

Therapies include cognitive-behavioral therapy; motivational enhancement therapy, behavioral couples therapy, 12-step facilitation, community reinforcement and family training, and individual drug counseling.

Adjunctive interventions and services include voucher-based reinforcement for abstinence, clinical case management and wraparound social services, linking of patients to AA, and posttreatment monitoring (telephone, Internet, and home visit).

Despite these very promising new developments, most addiction treatment is delivered within a specialty care treatment system that does not have the personnel, information management, or administrative support to implement most of these practices. Although there will be a continuing need for new and more sophisticated treatment interventions and components, there is a pressing need for financial and organizational development to permit the treatment system to provide the kind of quality care that is now possible.

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An initial stage in the clinical treatment of substance dependence is often the medical management of withdrawal states, which may be associated with a period of autonomic instability. For which of the following substances is the dependence illness not associated with a "true" physiological withdrawal state?
2.
Following the initial detoxification and stabilization of substance-dependent patients, the clinician proceeds to a rehabilitation treatment model. Rehabilitation models may have different lengths of treatment. Among the following rehabilitation models, which one may be associated with an indefinite time period?
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Adjunctive use of medications may be a critical part of the comprehensive care of the opioid-dependent patient. Which of the following statements about these medications is false?
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