Substance Use Disorders 421
Treating Substance Use Disorders
Three of the four Beatles were known to have at least one type of substance depen-
dence: George Harrison on nicotine (cigarettes), Ringo Starr on alcohol (for which
he received treatment), and John Lennon on alcohol and heroin. It is not known
whether any of the Beatles (other than Starr) received professional treatment for
their abuse or dependence. Lennon reportedly quit using heroin all at once—cold
turkey—without medical supervision.
We begin by considering the goals of treatment—what the best outcomes can be.Then we examine the treatments that target neurological, psychological, and social
factors, and, when appropriate, note the use of specifi c treatments for particular
types of substance abuse or dependence. However, as we shall see, many treatments
that target psychological and social factors can effectively treat abuse of and de-
pendence on more than one type of substance. Unfortunately, though, relapse rates
after any type of treatment are high enough that people with substance abuse and
dependence may need repeated episodes of treatment (NIDA, 2008f).
Goals of Treatment
Treatments for substance abuse and dependence can have two different ultimate
goals. One goal is abstinence—leading the person to stop taking the substance
entirely. When the goal of treatment is abstinence, relapse rates tend to be high
(up to 60% by some estimates), particularly among patients with comorbid dis-
orders (Brown & D’Amico, 2001; Curran et al., 2000; NIDA, 1999, 2008f). To
help patients achieve abstinence, pharmaceutical companies have focused their
efforts on developing two types of medications: (1) those that minimize with-
drawal symptoms, and (2) those that block the “high” if the substance is used,
thereby leading to extinction of the conditioned responses arising from substance
abuse and dependence.
Given that abstinence-focused treatments have not been as successful as hoped,an alternative goal of treatment has emerged, which focuses on harm reduction—
trying to reduce the harm to the individual and society that may come from sub-
stance abuse and dependence. For example, needle exchange programs give users
a clean needle for each heroin injection, which decreases the transmission of HIV/
AIDS because users don’t need to share needles that may be contaminated with
HIV. In some cases, harm reduction programs may also seek to find a middle
ground between abuse and abstinence: controlled drinking or drug use. For those
with symptoms of tolerance and withdrawal, which indicate dependence on al-
cohol or a drug, such a middle ground may be more diffi cult to achieve, however
(Rosenberg & Melville, 2005). In the United States, most treatment programs have
the goal of abstinence.
Targeting Neurological Factors
Treatments that are directed toward neurological factors approach substance use
disorders as diseases, and thus select medications as the treatment. In this section
we consider detoxifi cation and then turn to medications used to treat abuse of and
dependence on stimulants, depressants, narcotic analgesics, and hallucinogens.
Detoxifi cation
Detoxifi cation (also referred to as detox) is medically supervised withdrawal for
those with substance dependence. Detoxifi cation may involve a gradual decrease in
dosage over a period of time to prevent potentially lethal withdrawal symptoms,
such as seizures. People with alcohol, benzodiazepine, barbiturate, or opioid de-
pendence should be medically supervised when they stop taking the substance par-
ticularly if they were using high doses. Use of other drugs, such as nicotine, cocaine,
marijuana, and other hallucinogens, can be stopped abruptly without fear of medical
Two alternative goals guide treatments for
substance abuse and dependence. One goal is
abstinence—completely stopping the use of the
substance. The other goal is harm reduction—
lessening the harmful effects related to the
substance abuse or dependence (for example,
lowering the incidence of HIV/AIDS among heroin
users by discouraging needle sharing).Jack Merritt/AlamyDetoxifi cation
Medically supervised withdrawal for those
with substance dependence; also referred to
as detox.