Treating patients with multiple substance use in accordance with their personal treatment goals: a new paradigm for addiction treatment

Purpose

This paper aims to present the theoretical foundation and practical approach of “open-target addiction treatment” (OTAT). Traditional treatment programmes are usually-oriented towards fixed predefined goals (abstinence, reduced consumption and harm reduction) and often focus on one substance only (e.g. alcohol). However, as a rule, people who use drugs consume several substances and sometimes additionally exhibit behavioural addictions. For many of these addictions, there is more or less motivation for change, but commonly it is not abstinence as a consistent goal. The paradigm of OTAT systematically considers multi-substance use, expects high readiness to change and is aware that commonly clients lack the willingness to abstain permanently.

Design/methodology/approach

The theory and practice of OTAT involve three components, namely, first, to create a systematic inventory of all psychoactive substances consumed and addictive behaviours performed, second, to clarify, which substance-related change goals clients pursue and third, to choose adequate treatment options matching the substance-specific goals of the clients. Furthermore, OTAT includes didactic tools to support working along with these three steps (e.g. a set of cards to gain an overview over the psychoactive substances used and addictive behaviours performed).

Findings

The systematic implementation of OTAT requires fundamentally different concepts about addiction and its treatment, specific competencies of the staff and a corresponding portfolio of interventions within the treatment facilities.

Research limitations/implications

Future research should focus more on patients’ goal preferences and their impact on their willingness to take up treatment and its outcomes.

Practical implications

To implement OTAT treatment, institutions have to undergo a systematic process of team and organizational development.

Social implications

OTAT has the potential to reduce the treatment gap and to serve severely addicted individuals in a more comprehensive way.

Originality/value

The OTAT approach has not been described in the addiction treatment literature so far.

Reduced drinking and harm reduction in the treatment of alcohol use disorders

Purpose

The purpose of this paper is to give an overview of the scientific evidence for reduced drinking in alcohol use disorders. While the aim of alcohol use disorders (AUD) treatment usually focuses on abstinence, only a minority of individuals with AUD enter treatment. Lack of alternative treatment goals, including reduced drinking instead of abstinence, have been identified as a potential barrier for treatment entry. Epidemiological and treatment outcome studies reveal that a large proportion of individuals with AUD are able to substantially reduce their alcohol intake for a prolonged duration of time.

Design/methodology/approach

A narrative review of the literature on prevalence rates and health effects as well as evidence-based approaches fostering reduced drinking in individuals with AUD is presented.

Findings

Reduced drinking is associated with improvements in both morbidity and mortality. Research has identified evidence-based psychosocial and pharmacological treatment approaches; however, implementation is still scarce.

Originality/value

Target groups for interventions fostering drinking reduction instead of abstinence are defined and desiderata for further research are outlined.

Stellungnahme Dachgesellschaft Sucht:

Zusammenfassung. Hintergrund: Unterschiede in der Therapiezielfindung bei der Behandlung von Alkoholkonsumstörungen, die sich zwischen völliger Abstinenz, vermindertem Konsum (Schadensvermeidung) und „kontrolliertem Konsum“ aufspannen, werden seit vielen Jahren z. T. kontrovers diskutiert. Ziel: Ziel der Stellungnahme der Dachgesellschaft Sucht ist es, vorhandene empirische Erkenntnisse zu diesem Themenbereich zusammenzutragen und daraus Empfehlungen für den praktischen Umgang mit verschiedenen Therapiezielen wie Trinkmengenreduktion oder Abstinenz für die Patienten oder Klienten abzuleiten. An der Erstellung des Positionspapiers haben sich Vertreter verschiedener Fachgesellschaften (DG Suchtmedizin, der DG Suchtforschung und Suchttherapie sowie die Deutsche Gesellschaft für Suchtpsychologie) beteiligt. Eine Reihe von Forschungsdesideraten wird benannt.

[Providing for alcohol-related disorders in Germany : Demand, networking, and need for development]

Reducing alcohol consumption is one of the central health goals in Germany because the negative health consequences of excessive alcohol consumption are among the country's most serious and avoidable health risks. The care system for people with alcohol-related disorders comprises a large number of services, but due to the historically developed structures and respective responsibilities, it also includes many interfaces. Alcohol addicts often seek professional help only after many years of dependence. Especially in the areas of early detection and early intervention, there is a significant undersupply for people with alcohol-related disorders (see S3 guideline on alcohol-related disorders). Therefore, efforts should be made to promote the competence of the various actors (e. g. general practitioners, hospital and nursing staff, psychotherapists, case managers in job centers/employment agencies) to recognize alcohol-related disorders in their respective field of activity, to deal with them in a target-oriented manner, to identify risk groups, and to convey them according to their respective needs (e. g. in offers for qualified withdrawal, medical rehabilitation facilities (alcohol addiction treatment)). Accordingly, development potentials for promoting early and seamless access are presented using selected fields of action as an example. It is also emphasized that the implementation of case management is necessary to build bridges between the utility sectors. Finally, central aspects for the future development of the care system for people with alcohol-related problems are described.

Alcohol Dependence and Harmful Use of Alcohol

BACKGROUND

In Germany today, there are more than 1.8 million persons who are dependent on alcohol, and 1.6 million persons whose use of alcohol is harmful. The many complications of alcohol use are both mental and physical-in particular, gastrointestinal and neurological. Yet more than 80% of persons whose alcohol use is problematic still receive no treatment for their harmful use or dependence, despite contact with the health-care system.

METHODS

This article is a selective review of the pertinent literature, including guidelines, meta-analyses, and Cochrane Reviews.

RESULTS

The treatment is divided into an early interventional and motivational phase, qualified withdrawal, long-term cessation therapy, and a stabilization phase. Pharmacotherapy with acamprosate or naltrexone increases the rate of abstinence (number needed to treat: 12 and 20, respectively). If a patient lacks the motivation to abstain from alcohol entirely, reduced consumption can be agreed upon as a goal of treatment. 85% of patients relapse if no further treatment is given after initial detoxification.

CONCLUSION

What is needed in routine medical practice is practical diagnostic evaluation followed by individually tailored treatment, based on the severity of the condition, the development of the patient's motivation to be treated, and the local treatment options (e.g., outpatient addiction clinics, counseling centers, or day clinics).