Treatment principals and stages in treatment of alcohol and substance use disorders.

Last of 4 parts originally presented to Gainesville Fire and Rescue in a panel discussion on11/20/13. The first part discusses alcohol and prescription drug problems in firefighters and first responders, suicide, and contributors of stress and PTSD. The second part of this series describes indicators and behavioral signs of alcohol or drug intoxication, impairment and after-effects. A list of educational materials, resources, websites, and crisis lines for firefighters, law enforcement officers, and other first responders comprises the third part of this series.

Alcohol and Drug Treatment is the subject of many misconceptions and myths. Some of these misconceptions are created and sustained by the media, and by television “experts” and worse yet, highly dramatized “reality” shows. Research makes for good science but far less dramatic entertainment. It is important to understand that individuals can obtain help for developing alcohol, drug or other problems well before their lives are ruined and well before they have suffered losses or significant health effects. Not everyone seeks assistance without some encouragement, the "push" of legal or medical consequences, or that from a spouse, family or employer. Not everyone requires inpatient treatment or a 12-step program.

However, it is also important to note that many lives would be lost if it were not for interventions by employers, the law or family as well as recovery which may start in treatment and be sustained in 12-step programs. In fact, a common myth is that an individual has to want to enter treatment. Actual studies show little difference in treatment outcomes of those encouraged or "coerced" into treatment versus those seeking treatment entirely on their own. Most substance abuse professionals recognize that far from denial being present or absent, people are often in varying stages of readiness for entering treatment or recognizing they may need to take steps to prevent a problem or engage in efforts to bring a problem under control or treatment.

The Motivational Model of Recovery is a widely used conceptual model is that of an individual in different stages in their recognition of their substance abuse or dependency.

Once there is recognition that action must or should be taken, the next challenge is trying to understand treatment needs and the range of treatment options. Discussions of alcohol or substance abuse treatments must start with basic concepts and definitions of abuse and dependence.

The following is an introduction to the landscape of alcohol and drug treatment interventions:

• Tolerance – having to drink increasing amounts to achieve the previous desired effect

• Noticeable diminished effect when using the same amount as previously used

• Withdrawal symptoms - physical symptoms after going a short period without drinking

• Using alcohol or drugs to relieve or avoid withdrawal symptoms – such as “hair of the dog” – drinking to cure a hangover

• A significant amount of time is spent in trying to obtain the substance, use the substance, or recover form its effects

• “Seeking behavior” - only going to events that will be conducive to drinking or using drugs

• Knowledge of the compulsion to drink or use, with or without admitting it to others

Principles of Effective Treatment - National Institute of Health (NIH) Revised September 2009

Scientific research since the mid–1970s shows that treatment can help individuals stop using, avoid relapse, and successfully recover their lives. Key principles have emerged:

· Addiction is a complex but treatable disease that affects brain function and behavior.

· Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.

· Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment.

· Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

· An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.

· Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long–term drug abuse.

· Drug use during treatment must be monitored continuously, as lapses during treatment do occur.

· Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk–reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

Substance abuse treatment may be based on one of several traditional approaches: the Medical Model which focuses on the recognition of addiction as a bio/psycho/social disease, the need for life-long abstinence, and the use of an ongoing recovery program to maintain abstinence; the Social Model which focuses more on the need for long-term abstinence and the need for self-help recovery groups to maintain sobriety; and the Behavioral Model which focuses more on diagnosis and treatment of other problems or conditions.

Levels of care
*Criteria* *Dimensions*	*Level I* *Outpatient treatment*	*Level II* Intensive outpatient treatment	*Level III* Medically monitored intensive inpatient treatment	*Level IV* Medically managed intensive inpatient treatment
1 Acute intoxication and/or withdrawal potential	No withdrawal risk	Minimal withdrawal risk	Severe withdrawal risk but manageable in Level III	Severe withdrawal risk
2 Biomedical conditions and complications	None or very stable	None or nondistracting from addiction treatment and manageable in Level II	Requires medical monitoring but not intensive treatment	Requires 24-hour medical, nursing care
3 Emotional and behavioral conditions and complications	None or very stable	Mild severity with potential to distract from recovery	Moderate severity needing a 24-hour structured setting	Severe problems requiring 24-hour psychiatric care with concomitant addiction treatment
4 Treatment acceptance and resistance	Willing to cooperate but needs motivating and monitoring strategies	Resistance high enough to require structured program, but not so high as to render outpatient treatment ineffective	Resistance high despite negative consequences and needs intensive motivating strategies in 24-hour structure	Problems in this dimension do not qualify patient for Level IV treatment
5 Relapse potential	Able to maintain abstinence and recovery goals with minimal support	Intensification of addiction symptoms and high likelihood of relapse without close monitoring and support	Unable to control use despite active participation in less intensive care and needs 24-hour structure	Problems in this dimension do not qualify patient for Level IV treatment
6 Recovery environment	Supportive recovery environment and/or patient has skills to cope	Environment unsupportive but with structure or support, the patient can cope	Environment dangerous for recovery necessitating removal from the environment; logistical impediments to outpatient treatment	Problems in this dimension do not qualify patient for Level IV treatment
SOURCE: Center for Substance Abuse Treatment. Intensive Outpatient Treatment for Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series, No. 8. DHHS Pub. No. (SMA) 94-2077. Rockville, MD: Center for Substance Abuse Treatment, 1994b.

Ultimately, treatment decisions and guidance are best accomplished through highly professional care through physicians or psychiatrists trained in addiction medicine or clinical psychologists trained in addictions. A broad range of training is essential for assessment and referral for relevant medical concerns and complications, pharmacological approaches, and psychological assessment and testing to understand complicating mood, behavior, and personality contributors. The fact that dual or multiple diagnoses are the rule rather than the exception highlights the need for assessment and treatment professionals to have broad and deep mental health training far beyond alcohol and drug counseling.