430 CHAPTER 9
FEEDBACK LOOPS IN TREATMENT: Substance Use Disorders
At first glance, using medication to treat substance abuse or dependence might
seem like the perfect solution. Substance abuse disrupts neurological factors, and
how better to address that disruption than to use another substance? However, for
medications to work effectively, they must be taken regularly, which means that
users must remain motivated and willing to take them (psychological factor); in
addition, the risk of relapse is reduced when a user minimizes contact with people
and situations that trigger a desire to use the substance (social factors). Medications
may target neural communication and the relevant brain systems, but they don’t
address the whole person or the person’s context: friends, family, work and home
environments, and the subculture and community in which the person lives.
The neuropsychosocial approach leads us to categorize the various treatments
for substance abuse according to each one’s direct target. Regardless of which type
of factor is directly targeted, though, how exactly is treatment success determined?
The following considerations help to determine whether an intervention was suc-
cessful. Did the individual:- complete the treatment, or is he or she still using or abusing the substance? (Is he
or she abstinent—yes or no?) - experience fewer harmful effects from the substance? (Is he or she using clean
needles or no longer drinking to the point of passing out?) - decrease use of the substance? (How much is the person using after treatment?)
- come to behave more responsibly? (Does he or she attend regular AA meetings or
get to work on time?) - feel better? (Is the person less depressed, anxious, “strung out,” or are drug crav-
ings less intense?) - come to conform to societal norms? (Has he or she stayed out of jail?)
The treatments we’ve discussed can lead to improvement according to these
considerations, but different types of treatments provide different paths toward im-
provement. Moreover, like most cigarette smokers, many substance abusers may
quit multiple times. In addition, like studies of treatments for other types of disor-
ders, studies of treatments for substance abuse have found a dose-response relation-
ship: Longer treatment produces better outcomes than shorter treatment (Hubbard
et al., 1989; Simpson, 1984, Simpson, Joe, & Broome, 2002). And for those people
who abuse more than one type of substance, treatment is most effective when it ad-
dresses the entire set of substances.
The most robust finding about all of the treatments we’ve discussed is
that they work, at least in the short term. Project MATCH showed that CBT,
motivational enhancement therapy, and TSF were equally helpful. It also showed
that medication and social interventions are effective. Ultimately, all successful
treatments address all three types of factors that are identifi ed in the neuropsy-
chosocial approach. When people with substance abuse or dependence fi rst stop
abusing the substance, they will experience neurological changes that are, at
minimum, uncomfortable (neurological and psychological factors). Moreover,
how they think and feel about themselves will change (psychological factor)—
from “abuser” or “addict” to “ex-abuser” or “in recovery”. Their interactions
with others will change (social factors): Perhaps they will make new friends who
don’t use drugs, avoid friends who abuse drugs, behave differently with family
members (who in turn may behave differently toward them), perform better at
work, or have fewer run-ins with the law. Other people’s responses to them will
also affect their motivation to continue to avoid using the substance and endure
the uncomfortable withdrawal effects and ignore their cravings. Thus, as usual,
treatment ultimately relies on feedback loops among the three types of factors
(see Figure 9.13).P SN