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Outpatient and Inpatient Treatment for Substance Use Disorders

Outpatient Management

Outpatient care in the least restrictive environment possible is recommended for patients who are medically and behaviorally stable. Patients requiring more supervision may do best in an intensive day program or "partial hospitalization." As they progress through their treatment plan, patients may transition to less intensive programming with reduced frequency of outpatient visits. Intervention may consist of individual therapy, family therapy (including in-home therapy), group therapy, or a combination of approaches. Specific types of therapies used in substance abuse treatment programs include:
  • Cognitive behavior therapy (CBT) teaches patients the relationship between emotions, thoughts, and behaviors by thoroughly understanding the emotions that trigger specific thoughts (or vice-versa) that lead to behavioral choices. The ultimate goal is to choose consciously a more effective behavior. For example, a patient may experience feelings of rejection leading to thoughts of "I'm no good...I just want to escape," which may lead to "escape" through substance abuse. CBT will assist patients with awareness of their emotional experience, related thoughts, and options of behavioral choices. The patient in the above example would, rather than "escape" through substance use, talk about the feelings of rejection, challenge the reality of 'being no good,' and choose a healthy outcome. Patients are taught to identify and modify feelings that precede drug use, identify high -risk situations, and engage in more appropriate decision-making. CBT often involves relaxation and distraction techniques. Principles of CBT are often utilized in self-help manuals. Patients are taught the relationship between emotions, thoughts, and behaviors by thoroughly understanding the emotions which that trigger specific thoughts (or vice-versa) that lead to behavioral choices. The ultimate goal is to consciously choose a more effective behavior. For example, a patient may experience feelings of rejection which leads to thoughts of "I'm no good...I just want to escape" that may lead to "escape" through the use of substances. CBT will assist a patient with awareness of his emotional experience, related thoughts, and options of behavioral choices. The patient in the above example would, rather than "escape" through substance use, talk about the feelings of rejection, challenge the reality of 'being no good,' and choose a healthy outcome. Patients are taught to identify and modify feelings that precede drug use, identify high-risk situations, and engage in more appropriate decision-making. CBT often involves relaxation and distraction techniques. Principles of CBT are often utilized in self-help manuals.
  • Motivational enhancement therapy (MET) seeks to evoke internally motivated change by teaching decisional balances (the pros and cons of change), enhancing self-efficacy, identifying high-risk situations, and teaching strategies to make appropriate decisions in high-risk situations. This is a component of Motivational Interviewing (MI). MI is an office-based approach designed to shift a patient through the following sequential stages of change: pre-contemplative, contemplative, decision-making, action, and maintenance. This is the main therapeutic modality integrated in SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA).
  • Group therapy offers a safe environment for adolescents to discuss concerns about peer pressure, relationship, prevention of relapse, and other treatment issues. A "peer court" environment is instrumental to effect change during adolescence.
  • Twelve-step fellowships, such as Alcoholics Anonymous and Narcotics Anonymous, may lead to better levels of commitment to abstinence. Adolescents interested in these groups should be referred to a young people's group and seek a sponsor who is aware of his or her developmental level.
  • Family therapy methods include multidimensional family therapy (MDFT) and multisystemic therapy (MST). Individual and family sessions are typically conducted in the family's home. Therapists work closely with parents/caregivers to identify treatment goals, determine the causes of the substance abuse disorder, and implement therapeutic treatment. Effective family support is essential for adolescent (and adult) success with goals of abstinence.
  • Juvenile drug court relies on a case management system including positive reinforcement for compliance as well as clearly defined consequences for violation of court-ordered program guidelines; may reduce relapse and criminal activity while improving school, behavioral, and program outcomes.
  • Contingency management is based on the principle that if a good behavior is rewarded, it is likely to be repeated in the future. Patients are called upon to provide random urine samples for drugs of abuse at least once per week. Patients with negative test results are rewarded with items (such as gift certificates, music, sports equipment, or other items of interest) and/or increasing levels of freedom (from house arrest to full pre-determined freedoms). Studies in adults support the use of contingency management but little research on this treatment strategy has been done in the adolescent population.

Inpatient Mangement

Psychiatric hospitalization/acute residential treatment is reserved for medical detoxification and/or stabilization of co-morbid psychiatric disorders. If a patient is medically and/or psychiatrically unstable, referral to the emergency room for medical clearance is advisable and typically mandated. Once stable, patients may transition to an acute residential treatment facility for ongoing intensive therapy with close supervision and support.

Long-term residential treatment provides ongoing intensive daily therapeutic activities, including individual, group, and family therapy, with continued access to pharmacotherapy if needed. Placement typically ranges from 6-12 months and includes planning for transition back into the community.

Therapeutic communities provide a structured community environment for adolescents with severe chemical dependency and behavioral difficulties who may have failed less intensive treatments and cannot live at home. Placements range from 6-18 months.

Therapeutic schools function to meet the academic and therapeutic needs of adolescents with chemical dependency. Some function as day schools while others are residential. There are numerous private-pay facilities throughout the country. See the SAMHSA website: Substance Abuse Treatment Facility Locator (SAMHSA).

Wilderness therapy programs, while not designed specifically for those with substance abuse, often address the behavioral components underlying these disorders by applying outdoor-living skills, physical challenges, and survival techniques. Reports of participant deaths have brought attention to the safety of such programs. This type of therapy has not been well studied, and interested families should carefully research licensure status of programs they are considering.

Authors

Author: Mary Steinmann, MD - 4/2017