Week 11-Addiction Interventions Flashcards
What do Treatments for substance use disorders generally consist of?
-Pharmacological treatments for substance use vary in their mechanism of action, either blocking the effects of the substance on the brain, blocking an enzyme that builds up after consuming the substance (e.g., ALDH) or replacing the substance (e.g., nicotine)
-Pharmacological treatments do not address psychological or social/environmental reasons for substance use e.g., alcohol dependence tends to stem from a maladaptive coping mechanism
What do Treatments for Opioid use disorders, AUD and Smoking cessation focus on?
Opioid:
-Treatments focus on blocking opioid receptors such as naltrexone
-OR replace with a less addictive opioid such as methadone
AUD:
-Treatments like naltrexone blocks opioid receptors, reducing the release of dopamine and making alcohol consumption less pleasurable
-Treatments like Disulfiram builds up of acetaldehyde which leads to nausea, vomiting, tachycardia and dizziness
Smoking cessation:
-Treatment focuses on replacing the nicotine smokers receive from smoking with nicotine delivered in a different form (e.g., nicotine patches or gum, e-cigarettes)
What was the Social Basis for Heroin Use during the Vietnam War?
-Many soldiers became regular users of heroin during the Vietnam war
-Robins et al. (1974) - out of a sample of 450 enlisted men who returned to USA, 43% reported opiate use in Vietnam
-8-12 months after returning to USA, 10% reported any level of Heroin use, 1% reported becoming re-addicted
Why was there a reduction in heroin use with the soldiers from the Vietnam war?
-Not due to accessibility issues as p’s could obtain heroin with ease (Heroin is an opiate)
Reasons included:
-Fear of becoming addicted
-Experiencing adverse health effects
-Being arrested
-Disapproval of friends and families (Social acceptability lower in USA than Vietnam)
Other differences included:
-Price of drug
-Purity of drug
-Social acceptability of drug use
-Smoked rather than injected (due to purity in Vietnam)
What is the Biopsychosocial Model?
World <—–> Person
Social systems:
-Society
-Community
-Family
Psychological systems (experience and behaviour):
-Emotion
-Cognition
-Motivation
Biological systems (genetics and physiology):
-Organs
-Tissues
-Cells
What are some Biological Treatments for Opioid Use?
Opioid Antagonists:
-Antagonists (such as Naltrexone) binds to receptors and prevents an agonist (e.g., heroin) from binding to that receptor
-Works by blocking euphoric effects of opioids and suppresses opioid cravings
-Often used for those who have already stopped taking the opioid and are no longer dependent on the substance
Opioid Agonist Therapy:
-Treatment which administers a substance to substitute for a stronger agonist opioid (e.g., heroin)
-Works by preventing withdrawal and reduces cravings for opioid drugs
Agonist-Occupies and activates receptor
Antagonist-Occupies receptors but does not activate them. Block activation by agonists
-In the UK we move patients to methadone rather than heroin as an agonist
What is Naltrexone?
-Naltrexone is a medication approved by the Food and Drug Administration (FDA) to treat both Opioid Use Disorder (OUD) and AUD
-Available in a pill from AUD or as an extended-release intramuscular injectable for OUD (Can be injected into your arm and releases small doses)
-Naltrexone is not an opioid, not addictive and does not cause withdrawal symptoms with stop of usage
-Naltrexone is a pure opiate antagonist and has little or no activity SAMHSA (2023)
-Naltrexone competitively binds to such receptors and may block the effects of endogenous opioids. This leads to the antagonisation of most of the subjective and objective effects of opiates, including respiratory depression, miosis, euphoria and drug craving.
What is the evidence for the effectiveness of Naltrexone as a treatment?
Minozzi et al. (2011) reviewed 13 studies (N=1158):
-Compared oral naltrexone vs placebo or no pharmacological treatment
-Findings: no significant difference for opioid abstinence
-However, issues with data - only 28% of participants retained in treatment
-Authors conclude that the available data did not permit an adequate investigation of the efficacy of oral naltrexone
Originally used as a treatment for alcohol use disorder. (AUD).
-Oral naltrexone is different to when it is injected in your arm
-72% dropped out (retention bias-why are these people dropping out?)
Minozzi et al. (2011): What might have lowered retention and what are the side effects of oral naltrexone?
Form of administration:
-Oral naltrexone should be taken 3+ times per week
-Only the long-acting formulation is FDA approved as a medication for OUD
Side effects:
-Difficulty sleeping, anxiety, nausea, headaches (among others)
What is Opioid Agonist Therapy?
A treatment which administers a substance to substitute for a stronger agonist opioid (e.g., heroin)
2 main drugs prescribed for OAT:
1. Methadone - Methadone is an opioid analgesic indicated for the management of severe pain that is not responsive to alternative treatments. Also used to aid in detoxification and maintenance treatment of opioid addiction (Drugbank, 2023).
- Buprenorphine - A partial opioid agonist used for management of severe pain that is not responsive to alternative treatments. Also used for maintenance treatment of opioid addiction (Drugbank, 2023)
-Heroin is 10x more potent than methadone whereas oxycodone is 100x stronger than heroin (Drug in US)
-These help them to get off the stronger opiates as they’re safer and have fewer effects on the respiratory system
How effective is Opioid Agonist Therapy?
-As with heroin, methadone interacts with opioid receptors in the brain
Mattick et al. (2009):
-Methadone maintenance therapy vs no opioid replacement therapy for opioid dependence
-6 RCTs demonstrated that methadone appeared more effective than non-pharmacological approaches in retaining patients in treatment and suppressing heroin use (RR = 0.66, 95% CI (0.56-0.78)
-Risk to patients on methadone is opioid overdose death and this is elevated within the first 2 weeks of methadone treatment (Degenhardt et al., 2009)
Psychosocial Treatments: What are the strategies of CBT?
-Identification of both inter and intrapersonal triggers which may cause relapse
-Training to develop coping skills
-Drug-refusal skills training (Drug-refusal skills training is a big one as will power may be high but accepting it off someone else might not be)
-Function of analysis of substance use
-Increase of non-use related activities
Types of triggers targeted by CBT:
1. Cognitive
2. Affective
3. Situational
Psychosocial Treatment: What is Motivational Interviewing?
-A form of counselling involving a meeting between a client and counsellor
-The counsellor aims to understand how the client feels about the substance abuse problem - support is given for clients to make their own decision
-Discussion of possible consequences of altering or maintaining behaviour
-Discussion of client goals and how far/close client is to obtaining those goals
4 Main Principles (i.e., why it might work):
1. Express empathy - seeing world through client’s eyes (Empathy is important due to stigmas so can go a long way)
- Support self-efficacy - client held responsible for carrying out actions to change
- Roll with resistance - counsellor does not fight client resistance
- Develop discrepancy - perceiving discrepancy between where they are and where they want to be
Psychosocial Treatments: What is Contingency Management?
-Individuals are reinforced/rewarded for positive change in behaviour
-Often used in substance use treatments e.g., the incorporation of a monetary reinforcer for a negative drug sample
-Recommended by UK National Institute for Health and Clinical Excellence
-Voucher-based reinforcement therapy (a type of contingency management) shown to be effective in the treatment of substance use disorders (Lussier et al., 2006)
What did Amato et al. (2011) find when reviewing Psychosocial and Pharmacological treatments combined?
-Reviewed the effectiveness of psychosocial intervention in combination with agonist maintenance treatment vs agonist treatment for opiate dependence
-Reviewed 35 studies (N=4319) included 13 different psychosocial interventions
Found no evidence that psychosocial interventions improved:
-Retention in treatment (RR = 1.03, 95% CI [0.98, 1.07])
-Abstinence of opiates (RR = 1.12, 95% CI [0.92, 1.37])
-From a psychological viewpoint it is looking quite weak
What did Rice et al. (2020) find when reviewing Psychosocial and Pharmacological treatments combined?
-Did an updated systematic review comparing opioid agonist therapy only vs. OAT + psychosocial therapy
-Reviewed 72 RCTs
Key findings:
-No difference between the 2 groups for opioid use and opioid abstinence
-Reward-based interventions (e.g., contingency management) + OAT more effective than OAT alone for treatment retention
Why might studies show a lack of enhanced effectiveness of psychosocial and pharmacological treatment combined and what could be done about this?
-Typically psychosocial treatments for SUDs (including OUD) involves following a therapist manual
-This can limit the amount of flexibility for tailoring treatments to the patients’ preferences
Alternative approach- Case-formulation approach:
-Involves selection of interventions through discussion with the patient - focuses on identifying cognitive, affective, interpersonal factors which may maintain the disorder
-Focuses on the psychological roots
What did Marsden et al. (2019) do in their study investigating psychosocial treatments for opioid use?
-Individuals from the UK who were seeking opioid agonist therapy were recruited and allocated to either the psychosocial intervention group (psychosocial + OAT; N=136) or the control group (OAT; N = 137)
-Participants in the psychosocial intervention group completed a case formulation with a psychologist
-Toolbox of methods: CBT, contingency maintenance, 12-step group facilitation, engagement of partners and/or family members in participants’ treatment
-Lasted for 12 weeks
-Primary outcome: AT 18 weeks after condition allocation - treatment response (i.e., no reported use of opioid use in past 28 days, negative urine test over same period)
What were the key findings in Marsden et al’s (2019) study?
-PDA = percent days abstinent in last 28 days
-WSAS = work and social adjustment scale
-Psychosocial intervention increased odds of greater PDA and WSAS scores after 18 weeks compared to control group
Why do people drink alcohol? (Cox & Klinger, 1988)
People drink alcohol for various reasons:
-Biological (drinking is rewarding)
-Psychological (drinking is enjoyable)
-Social/Environmental (peer drinking)
What Psychosocial Treatments are there for AUDs?
-A range of treatments exist which focuses on psychological processes
Many overlap with psychosocial treatments of other disorders (such as OUD):
-CBT
-Motivational interviewing
-Family/social support
-12-step intervention programmes (e.g., alcoholics anonymous)
12-step:
-Self-help group lead by professional or former alcohol dependent
-Offers a model of abstinence for those recovering from alcohol dependence
What is the effectiveness of Motivational Interviewing and Substance Abuse? (Smedslund et al., 2011)
-59 studies (N=13,342) - 29 studies measured alcohol abuse
-Compared motivation interviewing to no treatment
-A significant effect on substance use - strongest at post-intervention (immediately after the intervention had finished)
-Significant effect also shown for short and medium-term follow-up
-Importantly though, no significant differences shown between motivational interviewing and treatment as usual for substance use disorders
-This treatment does work well but starts having less of an effect as time goes by
How effective is CBT for alcohol and drug disorders? (Magill & Ray, 2009)
-Meta-analysis including 53 controlled trials using CBT
-Participant were adults diagnosed with alcohol or illicit drug use disorders
-CBT shown to produce a small effect (hedges g = 0.154, p <.005)
-The effect size diminished as follow-up period increased
-6-9 months follow-up – hedges g = 0.1, p <.005
-12 months follow-up – hedges g = 0.096, p <.05
-The effect of CBT was greatest when comparison was with a no-treatment control (hedges g = 0.796, p <.005).
-Psychosocial treatment great during intervention, has an effect with follow up but less after
How effective is CBT for alcohol and drug disorders? (Magill et al., 2019)
Examined 30 RCTs, testing the efficacy of cognitive-behavioural therapy on alcohol-use and substance-use disorders.
CBT vs minimal therapy:
Showed moderate and significant effect size
CBT vs non-specific therapy/treatment:
Showed effect for consumption frequency and quantity at early follow-up (but not late follow-up).
CBT vs specific therapy (e.g., motivational interview, contingency management):
Nonsignificant difference across outcomes and follow-up time points.
Conclusion – CBT more effective than no treatment, minimal treatment, or non-specific control, but not specific therapy.
