Treatment Options for Alcohol and Substance Misuse

Treatment Options for Alcohol and Substance Misuse
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Brief Intervention

Patients who screen positive for unhealthy alcohol use, but do not have a diagnosed alcohol use disorder, should be provided a single initial brief intervention regarding alcohol-related risks and the advice to abstain or drink within nationally established age and gender-specific limits for daily and weekly alcohol consumption[1]. A brief intervention for unhealthy alcohol use can occur in a single session or multiple sessions and includes motivational discussion focused on increasing insight and awareness regarding alcohol use and motivation towards behavioral change. This intervention can be conducted by a provider or counselor and is not limited to addictions specialists. It can be used as stand-alone treatment for those at risk, as well as a way to engage those individuals in need of a more significant level of care. Brief intervention includes:

  1. Concern that the individual is drinking at unhealthy levels known to increase risk of alcohol-related health problems
  2. Feedback linking alcohol use and health, such as personalized feedback explaining the interaction between alcohol use and individual medical concerns or general feedback on health risks associated with drinking
  3. Advice to abstain if there are contraindications to drinking or to drink below recommended limits
  4. Support for the individual in choosing a drinking goal
  5. Referral to specialty addictions treatment if appropriate

Counseling Services and Resources

If it is determined that a higher level of treatment is required, counseling services are available through each service:

Overall Treatment Considerations

Providers should offer referral for specialty alcohol or substance use disorder (SUD) care for patients if they are diagnosed with a SUD; may benefit from additional evaluation of their substance use and related problems; or are willing to engage in specialty care. There are many factors that help to determine the appropriate level of care for SUD treatment, such as patient preference, patient motivation, patient willingness and available resources. There is no clear evidence to support using a standardized assessment to determine initial intensity and setting of SUD care rather than the clinical judgment of trained providers[2]. For patients with substance use disorders in early recovery or following relapse, providers should promote active involvement in group mutual help programs using a systematic approach such as peer linkage, network support or 12-step facilitation. Patients in intensive outpatient or residential treatment should be offered ongoing systematic relapse prevention efforts or recovery support individualized on the basis of treatment response. Patients who do not respond to treatment or relapse should not be automatically discharged from treatment. The treatment information presented for these SUDs is consistent with the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. However, providers should consider these evidence-based treatment recommendations along with individual patient needs and characteristics, to include patient preferences and provider competencies, when making treatment decisions. Professional consultation is recommended for complex patients.

Treatment for Alcohol Use Disorder

There are both psychosocial intervention and pharmacotherapy treatment options recommended for patients with alcohol use disorders. Providers should consider patient preference as well as their own competencies when selecting which intervention to offer. The following psychosocial interventions are recommended per the VA/DoD CPG for SUD.

  • Cognitive behavioral therapy for substance use disorders: focuses on teaching patients to modify both thinking and behavior related to alcohol use, as well as to change other areas of life functionally related to alcohol use through techniques such as structured practice outside of session, including scheduled activities, self-monitoring, thought recording and challenging, and interpersonal skills practice.
  • Community reinforcement approach: a comprehensive cognitive-behavioral intervention that focuses on environmental contingencies that impact and influence a patient’s behavior through increasing positive reinforcement, learning new coping behaviors, and involving significant others in the recovery process.
  • Motivational enhancement therapy: uses principles of motivational interviewing to heighten awareness of ambivalence about change, promote commitment to change and enhance self-efficacy through a structured intervention based on systematic assessment with personalized feedback.
  • 12-step facilitation: aims to increase the patient’s active involvement in Alcoholics Anonymous (AA) or other 12-step-based group mutual help resource delivered as 12 sessions of individual therapy in which a provider encourages engagement with AA and walks a patient through the first steps of AA.
  • Behavioral couples therapy for alcohol use disorder: focused both on reducing alcohol use in the identified patient and on improving overall marital satisfaction for both partners using a series of behavioral assignments to increase positive feelings, shared activities, and constructive communication.

For patients with moderate to severe alcohol use disorder, there are several pharmacotherapy treatments recommended, to include the following medications:

  • acamprosate
  • disulfiram
  • naltrexone – oral or extended release
  • topiramate

For patients for whom first-line pharmacotherapy is inappropriate or ineffective, there is some evidence to support offering gabapentin as an alternative pharmacotherapy[3]. For more information regarding pharmacotherapy, refer to the VA/DoD CPG for SUD or consult with a medical provider.

Treatment for Opioid Use Disorder

Treatment for opioid use disorders primarily involves pharmacotherapy, particularly given the high mortality associated with these disorders[4]. Use of buprenorphine/naloxone or methadone in the context of an opioid treatment program has been found to be effective. For patients with opioid use disorder who are not appropriate for an opioid agonist treatment and have established abstinence for a sufficient period of time, extended-release injectable naltrexone can be offered as an alternative treatment.

Addiction-focused medical management is recommended for patients treated with buprenorphine. This treatment involves a manualized psychosocial intervention designed to be delivered by a medical provider in a primary care setting using strategies to increase medication adherence and monitoring of substance use and consequences, as well as supporting abstinence through education and referral to support groups. It typically includes monitoring self-reported use, laboratory markers and consequences; monitoring adherence, response to treatment and adverse effects; education about substance use disorder consequences and treatments; encouragement to abstain from non-prescribed opioids and other addictive substances; and encouragement to attend community supports for recovery such as mutual help groups and to make lifestyle changes that support recovery.

Other psychosocial interventions, such as individual counseling or contingency management (a motivational intervention that uses behavioral reinforcement principles such as providing vouchers, money or other rewards to encourage behavior change), can be offered to patients with consideration to patient preferences and provider training/competence. However, evidence does not support the effectiveness of psychosocial interventions as an independent treatment modality for patients with opioid use disorder[5].

Treatment for Cannabis Use Disorder

For patients with cannabis use disorder, there are several psychosocial interventions recommended per the VA/DoD CPG for SUD, including cognitive behavioral therapy, motivational enhancement therapy, and combined cognitive behavioral therapy/motivational enhancement therapy. There is no clear evidence to support the use of pharmacotherapy in the treatment of cannabis use disorder.

Treatment for Stimulant Use Disorder

There is no clear evidence to support the use of specific pharmacotherapy for the treatment of patients with cocaine use disorder or methamphetamine use disorder. However, there are several psychosocial interventions recommended, to include cognitive behavioral therapy, recovery-focused behavioral therapy comprising general drug counseling and a community reinforcement approach (a comprehensive intervention that combines cognitive behavioral therapy, couples counseling and other recovery focused components), or contingency management in combination with one of the noted psychosocial interventions[6].