Advanced Substance Misuse Treatment Interventions - Essay Example

Running Head: ADVANCED SUBSTANCE MISUSE TREATMENT INTERVENTIONS Advanced Substance Misuse Treatment Interventions [Institution's Name] Table of Content Advanced Substance Misuse Treatment and Interventions Introduction The term substance abuse can be defined as an excessive use of addictive substances. Due to its misuse, the functioning of ones body and mind can alter resulting in adverse social consequences, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. This term mainly refers to overeating, cigarette smoking, alcohol abuse, or drug abuse. Alcoholism Alcohol is one of the most frequently abused substances. Similar to other substance abuses, alcohol leads to misconduct, unacceptable social behavior, and impairment of an individual's performance of duty, physical or mental health, financial responsibility or personal relationships. It is not understandable why some people develop alcohol use troubles and others do not, although there is a strong hereditary link. Firstly, alcohol is often used to pacify pain or hide insecurities. Over time, abuse and dependence can build up. Many people often fail to understand the difference between alcohol abuse and alcohol dependence. Alcohol abuse occurs when the drinker frequently drink alcohol even though it causes significant problems in the drinker's life. Abuse disrupts the drinker's relationships, causes the drinker to miss work (often due to hangovers), and neglect personal and work obligations. It can lead to legal problems, such as being arrested for disorderly conduct or drinking while driving. The drinker doesn't have to drink daily or drink large amounts of alcohol to have an abuse problem. Whereas if alcohol abuse continues, it can lead to dependence - a physical and emotional addiction to alcohol. The drinker may not be able to quit drinking on the drinker's own, even when the drinkers want to. With dependence, the drinker feel forced to drink, and it dominates the drinker's life. The drinker may plan the drinker's activities around alcohol and may drink secretly or hide the amount that the drinkers drink. Over time, it will take larger amounts of alcohol before the drinker feel its effects. The drinker may get irritable, start to vomit, sweat and shake when the drinker are unable to drink or try to quit on the drinker's own. Alcohol abuse can be present if these symptoms exist: One of the early signs of an alcohol problem is having blackouts-periods of time where the drinker were awake but do not remember what occurred while the drinker were drinking. For example, the drinker is injured while drinking but don't remember how it happened. Having unexplained injuries related to alcohol use or continue to drink despite the problems it causes. The person may also become physically aggressive when intoxicated. Many people who abuse alcohol deny they have a problem and consider themselves "social drinkers" because they do not drink every day. Alcohol abuse can develop in a short time or gradually over the drinker's lifetime. In the beginning, the drinker's drinking may not appear to be any different from the way other people drink. Some people drink only occasionally but drink a lot (binge drinkers), which can lead to alcohol abuse. Over time, the drinker's drinking may become a way for the drinker to feel normal or to cope with life's problems. There are certain risk factors which increase the chance of alcohol abuse. Having a family history - this includes a genetic link - and exposure to alcohol at a place where the person grows up. Using alcohol at an early age proves to be dangerous because the earlier the exposure, the higher the risk of developing alcohol use problems as an adult. Using or abusing other substances such as nicotine, illegal drugs, or prescription medications may also increase abuse of alcohol. Treatment and Cure Although several innovative substance abuse counseling strategies have emerged recently, none have exhibited greater promise than those based on brief intervention theory. Numerous studies provide evidence of the clinical effectiveness of a brief intervention approach to addictive behaviors (Baer, Holt, & Lichtenstein, 1986; Lichtenstein & Glasgow, 1997; Rollnick & Heather, 1982; Rychtarik, Prue, Rapp, & King, 1992). However, the benefit such an approach offers counselors whose practice is closely regulated by third party payers has not been reviewed thoroughly. Therefore, our purpose, here, is to present the advantages a brief intervention approach has for substance abuse counselors working in a rapidly changing health care environment. Specifically, a rationale for brief intervention addiction counseling, a review of the tenets of brief intervention theory, a model to operational brief intervention theory for addiction counseling, and the implications a brief intervention approach has for substance abuse counselors who work in managed care settings (including different levels of care, brief interventions, and outcome evaluation) are discussed. Abstinent and Harm Reduction Approaches Abstinent is one of the best's solutions to Harmful drinking. It means complete discontinuation of alcohol intake. However, it is by no chance an easy feat, and to address this tough issue, there are many Harm Reduction techniques which help in alcohol abstinence. Harmful drinking treatment services for the elderly are delivered in two general settings--inpatient and outpatient. Inpatient settings mostly consist of short-term residential programs. They often are used for the early phases of treatment, particularly acute detoxification. Outpatient settings provide more long-term maintenance treatment, with group meetings and individual counselling offered once or twice a week. Because of current concern over increasing health care costs, more emphasis now is being placed on outpatient care during all stages of recovery. As a result, successful models of outpatient detoxification and intensive day treatment services have been developed. Brief Interventions In 1980 a World Health Organization Expert Committee called for the development of efficient methods to detect people with harmful alcohol consumption before health and social consequences become pronounced (WHO, 1980). Since then, the concepts of early identification and brief intervention have attracted widespread attention from researchers and policy makers, as indicated by the growing amount of clinical and applied research being conducted throughout the world. In the last decade the development of effective, inexpensive screening and brief interventions for alcohol misuse has moved beyond the stage of clinical trials to the point where national dissemination plans are being considered (Higgins-Biddle et al., 1997). Growing evidence indicates the effectiveness of brief interventions in decreasing alcohol use by heavy drinkers who are not yet physically dependent on alcohol (Institute of Medicine [IOM] 2000). Physicians and other health care professionals deliver these interventions based on an assessment of the patient's alcohol use and alcohol-related problems. During a brief, highly directive consultation, the professional informs the patient about the assessment results (e.g., elevated liver functions, absenteeism or lateness at work, or alcohol-related arrests). The professional then offers clear strategies, such as goal setting and contracting, to reduce future drinking. Researchers have studied the effectiveness of brief interventions in inpatient and outpatient health care settings. The findings indicate that brief interventions reduce alcohol use and improve health status when compared with no intervention (Wallace et al.P.663--668, 2000) and can be as effective as more extended treatment for the elderly protocols (Chick et al. P. 159-170, 2000). Bibliotheca1, a type of brief intervention in which elderly patients receive written materials on the harmful effects of alcohol and guidelines for reducing drinking, also has been found to reduce alcohol consumption and associated problems (Sanchez-Craig et al. P. 395-404, 2000). These interventions represent a potentially powerful and cost-effective tool for early treatment for the elderly of heavy drinkers identified in a variety of settings. Brief interventions constitute a variety of activities directed at people who engage in risky drinking, but who are not severely alcohol dependent. These interventions are characterized by their low intensity and short duration; typically consisting of 5-60 minutes of counselling and education, with usually no more than three to five sessions. They are intended to provide early intervention, before or soon after the onset of alcohol-related problems. The content of brief interventions has varied somewhat in research and demonstration projects. Most programs are instructional and motivational, designed to address the specific behaviour of drinking with information feedback, health education, skill-building and practical advice, rather than with psychotherapy or other specialized treatment techniques. It is not clear what "brief" or "minimal" interventions are (Heather, 1989, 1995; McKay & Maisto, 1993), although both use mostly didactic methods (Sanchez-Craig & Wilkinson, 1989), which Heather (1995) suggested may reduce the stigma attached to the label of "treatment." Babor (1994) defined a "minimal" intervention as the "shortest or least intensive activity that has a therapeutic or preventive effect" (p. 1128), such as 5 minutes of succinct advice and exhortation, usually provided in one contact. This is analogous to "simple advice" that involves prescribing abstinence or a reduction in drinking without providing guidelines for doing so (Sanchez-Craig & Wilkinson, 1989). Miller and Rollnick (1991) defined advice as a recommendation provided by the counsellor to the client regarding the identification of a clear goal (e.g., eliminating further hazardous driving, decreasing amount of alcohol used). Despite Miller and Rollnick's clarification that the selection of a goal is left up to the client have been criticized for advice-giving, equating it with an "authoritarian and paternalistic" approach (p. 335). They stated that unsolicited advice may be resented by patients and may contribute to "feelings of helplessness and resistance to future change" (p. 336). They recommended a more patient-cantered approach to brief intervention in which accurate and objective information requested by the patient is provided, free of direct persuasion. "Brief," on the other hand, generally refers to treatment provided in one to three sessions with clients presenting with low or moderate levels of alcohol dependence (Babor, 1994). These approaches carefully instruct clients in their efforts to attain sobriety or maintain a reduction in drinking (Sanchez-Craig & Wilkinson, 1989) and include concrete, individualized, and motivational feedback (Holder et al., 1991; Marlatt et al., 1998). This is further differentiated from "intensive" treatment or "brief therapy" (Babor, 1994; IOM, 1990), which takes place in eight or more sessions and is indicated for clients whose problems are more severe, or who have not benefited from a minimal or brief intervention, or who have refused referral for specialized treatment. McDuff and Solounias (1992) described the use of a "brief psychotherapy" model in a 28-day residential treatment program. According to my definition of brief interventions, McDuff and Solounias's approach would not be considered a "brief intervention" because of the extended length of time involved, the setting, and the use of psychotherapy, rather than primarily a didactic format. They concluded, however, that "the principles of brief psychotherapy fit well with the current design of substance abuse treatment programs, in which treatment is often divided into discrete and predictable blocks of time" (p. 169). During the past two decades, more than 40 randomized controlled trials have been conducted to evaluate the efficacy of brief interventions with risky drinkers. The results of these trials have been summarized in several integrative literature reviews and meta-analyses (Bien, Miller & Tonigan, 1993; Babor, 1994; Kahan, Wilson & Becker, 1995; Wilk, Jensen & Havighurst, 1997; Poikolainen, 1999). Higgins-Biddle & Babor (1997) conducted a secondary analysis of research data on more than 20 000 drinkers reported in 14 random assignment studies having quantitative estimates of alcohol consumption before and after exposure to a brief intervention, and comparable information from an untreated control group that did not receive an intervention. The results showed a net reduction in the intervention groups (minus reductions in controls) of 21% for males and 8% for females. Characteristics of Brief Interventions Several authors have delineated the common elements of brief interventions (Allen et al., 1995; Babor, 1994; Bien et al., 1993; Heather, 1989, 1995; McKay & Maisto, 1993). First, these approaches involve less specialist time than would normally be devoted to intensive chemical dependency treatment, such as one or two sessions of assessment and advice or feedback for 5 to 30 minutes per session. Second, brief interventions are usually developed by specialists to be delivered by other professional groups who work with clients other than problem drinkers. The settings for brief interventions, therefore, are varied, from primary health care centres, to community mental health agencies, to work settings. Any brief intervention that intends to induce change in problem drinkers should include the following elements proposed by Miller and Sanchez (1994) and known by the acronym "FRAMES": (1) feedback of personal risk or impairment, (2) emphasis on personal responsibility for change, (3) clear advice about change, (4) a menu of alternative change options, (5) therapist empathy, and (6) facilitation of client brief intervention or optimism. Sanchez-Craig (1990) maintained that brief interventions for alcohol problems are always an option regardless of a client's level of alcohol dependence. A more important determinant, she stated, is the client's level of willingness to assume responsibility for the course and outcome of treatment. The prevailing consensus, however, is that brief interventions are designed primarily for early-stage problem drinkers (Allen et al., 1995) who have only low or moderate levels of alcohol dependence and "not intended for people whose problems are sufficiently serious to deserve the label 'alcoholism'" (Heather, 1995, p. 105). For this reason, the goal of such efforts is both abstinence and moderate, non-problem drinking. Consumption of alcohol is the target or focus, and harm-free drinking is the goal. Although "the degree of alcohol dependence is a more important criterion than the extent of alcohol-related problems" (Heather, 1995, p. 106), clients with more serious problems "may be appropriate candidates for brief interventions, particularly when access to intensive treatment is limited or where there are psychological barriers to seeking help from specialist services" (Heather, 1995, p. 106). In addition, there are individuals with substantial or severe alcohol problems who will not agree to specialized and intensive treatment (IOM, 1990). Miller (1992) discussed brief interventions as one of five impelling reasons for optimism in substance abuse treatment because of their ability to "be provided to larger populations than can be attracted or served by formal treatment" (p. 97). Brief interventions for the alcohol dependent client can be ethically justified, therefore, in certain circumstances, especially if the client would otherwise receive no help at all (Heather, 1995). Appropriate referrals can then be made and the brief intervention can serve as an impetus for or a prelude to more intensive care (McCrady, 1991). Although the cumulative evidence of randomized controlled trials conducted in a variety of settings shows that clinically significant effects on drinking behaviour and related problems can follow from brief interventions, the results have not always been consistent across studies (Poikolainen, 1999). There is little evidence, for example, that interventions are beneficial for alcohol-dependent individuals (Mattick & Jarvis, 1994). Screening is, however, justified for alcohol dependence because it can lead to referral for appropriate treatment, as well as improving accuracy of diagnosis and treatment for complicating or concurrent disorders. Patients who are severely dependent on alcohol are typically referred for more intensive treatment, the goal of which would usually be abstinence. Risky drinkers, on the other hand, may play a more active role in choosing their own goals. Some may seek abstinence, but others may seek to reduce their drinking. Conclusion and Recommendation In summary, heavy drinking, in the form of high quantities of alcohol consumed per occasion and a high overall volume consumed, has been found to be significantly associated with poorer perceived health. Although the size of the effect has been fairly small, this relationship is an important one in that alcohol use is a potentially controllable factor in the health of older people. Although the general consensus is that "minimal" and "brief" interventions are intended for early problem drinkers and those who have low levels of alcohol dependence, provisions are made for more severely dependent clients (Heather, 1995; IOM, 1990; Sanchez-Craig, 1990). Accommodations are made based on the fact that such clients may not otherwise receive treatment, due to factors of accessibility and preference. These may include using the brief intervention to motivate alcohol dependent clients to enter long-term treatment, representing "the first step of a series of progressively more intensive interventions" (Marlatt et al., 1998, p. 614). Guidelines for continuing and future research in this area have been proposed (Babor, 1994) and recommendations made for clinician practice and training (Sanchez-Craig, 1990; Sanchez-Craig & Wilkinson, 1987; Zweben et al., 1988). Rollnick et al. (1997) recommended including severely dependent drinkers in outcome trials for whom a brief intervention could serve as an initial review of health behaviour and during which a determination could be made regarding appropriate referral. A similar use of brief interventions (i.e., as a screening method, or as a "stepping stone" or orientation to more intensive treatment) could be formulated for clients with additional health problems or co-occurring mental health symptoms, or both. Just as extensive treatments have the potential to be misused through indiscriminate application (Sanchez-Craig & Wilkinson, 1989), so do brief interventions. Careful and comprehensive screening and assessment procedures should, therefore, be used (Allen et al., 1995), and treatment providers should have extensive addictions-related knowledge to respond authoritatively and accurately to questions the client may have about the consequences of continued alcohol consumption (Sanchez-Craig & Wilkinson, 1987). Clinician flexibility, however, is essential, so that clients who exhibit various levels and types of alcohol-related problems can be served (Miller, 1992). As the chemical dependency treatment field continues to move away from an exclusive concentration in specialized facilities and into the community, the assessment and diagnostic skills of the clinician, as well as his or her ideological flexibility, will determine the effectiveness of such methods. 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