Integrating pharmacotherapy with treatment planning for alcohol dependence

An introduction from Addiction Professional's Editor

This is the fourth in a series of six articles designed to provide you with the latest information on the use of medications in alcohol dependence treatment. Medications (pharmacotherapy) used as adjuncts to counseling techniques and biopsychosocial, educational, and spiritual therapies are an increasingly important part of a comprehensive treatment approach for alcohol dependence.

Expanding knowledge of how medications may interact with and complement counseling techniques will help the addiction counseling community optimally coordinate care of patients with other treatment providers. Thus, the article series Pharmacotherapy: Integrating New Tools Into Practice will not only provide the latest efficacy and safety data on these medications, it will also explore how we can build better relationships among addiction professionals and medication prescribers. The series will also examine the current barriers to medication use in treatment while offering potential solutions.

The first three articles in this series, which began in the January/February 2007 issue, addressed the topics of facilitating the process of change through medication use; examining recent study results on the approved medications for alcohol dependence; and overcoming biases against greater use of medications in treating alcohol dependence. In this fourth article, Gerald Shulman, MA, MAC, FACATA, describes how nonprescribing clinicians can integrate medication into their treatment planning efforts. The next article, in the September/October issue, will discuss the importance of building cooperative relationships between addiction treatment professionals who provide counseling and medication prescribers.

Successful treatment of individuals dependent on alcohol requires having a treatment plan that is jointly developed by the clinician and patient. This plan must precisely state the individual's problems, goals for treatment, specific measurable objectives, and treatment interventions. Such a plan provides the link between the results of the individual's assessment, which begins at intake, and the actual treatment, which is updated as the individual progresses through treatment. It can help determine the level of care and facilitate appropriate referrals to other treatment providers, such as physicians or others who prescribe medications.

Although they do not prescribe, addiction counselors involved in patient care need to be aware of the goals of pharmacotherapies and be prepared to collaborate in monitoring and supporting them. Counselors need to develop an understanding of the role and action of pharmacotherapies, ensure that the treatment plan details the processes for how they will be used and managed during treatment, and support their use with the patient.

This article describes the key components and steps in treatment planning for alcohol-dependent individuals, with a focus on how counselors and other nonprescribers of medication can integrate medication into their treatment plans and their practices.

Creating a treatment plan

A well-constructed treatment plan first requires comprehensive assessment of the individual. The American Society of Addiction Medicine (ASAM) Patient Placement Criteria, Second Edition-Revised (PPC-2R) details six dimensions by which patients can be assessed. These categories are: 1) the individual's potential for intoxication and withdrawal; 2) co-occurring medical conditions; 3) emotional, cognitive, or behavioral complications; 4) the individual's readiness to change; 5) the potential for relapse or continued use; and 6) the individual's living and recovery environment. 1 Clinicians can use the ASAM PPC-2R as a guide to evaluate their patients' strengths and the severity of their problems, and to determine the nature and intensity of treatment.

Identifying the severity of an individual's problems and his or her particular needs in recovery is particularly important because this process allows the patient and clinician to create an individualized treatment plan. A “one-size-fits-all” plan does not address specific patient treatment issues or account for all of the biopsychosocial or spiritual factors that affect each person's situation. Additionally, individualized treatment plans, when developed collaboratively with the patient, may make it easier for the clinician and the patient to develop a rapport—the patient who participates in such a plan is likely to be more engaged and stay in treatment longer, which increases the likelihood of treatment success.2,3

A well-conceived treatment plan includes statements that encapsulate the patient's identified problems, goals, and objectives, as well as the interventions to be used in treatment, the time frames, and the staff responsible for treatment. The patient's problems must be clearly identified, precisely described, and prioritized by severity or risk. These statements should use specific language and not be just a diagnosis, such as “alcohol dependence with bipolar disorder.” For example, statements that precisely describe a patient's inability to comprehend the destructiveness of his disease might read, “The patient acknowledges his performance at work is suffering but does not recognize or may be unwilling to admit to how his drinking may be a contributing factor.” This detailed description is more useful than “the patient denies a problem with alcohol” and allows the patient and clinician to develop more focused discussions—such as regarding alcohol's effects on productivity—and create specific goals to address alcohol-related difficulties. The six dimensions described by the ASAM PPC-2R can be used to organize and prioritize the specific problems and challenges faced by the patient.

Treatment goals are global statements describing the resolution of the target problems in nonmeasurable terms. Objectives are the behavioral and measurable actions patients will take to meet those goals, and the treatment interventions are actions taken by the clinician to help patients achieve the goals. The acronym “SMART” captures the important attributes needed to execute a treatment plan: Plans and goals should be specific, measurable, attainable, realistic, and time-sensitive or -limited, meaning there should be time frames for accomplishing goals and completing treatment milestones.4 Thus, one of the keys to treatment success is setting agreed upon goals and objectives that the patient and the clinician have clearly defined and that the patient perceives to be achievable and truly realistic. Thus, smaller achievements that can be accomplished within shorter time frames are more desirable than objectives that exceed the patient's capabilities. Objectives also need to be measurable in order to monitor progress throughout treatment. Treatment plans should be continually revised and developed to reflect the patient's movement through the stages of recovery or when new problems are identified.

Including medications in planning

Successfully integrating medication use into treatment planning may be challenging for clinicians who don't prescribe. Some clinicians may have limited experience or knowledge of how to recommend or support medication use if that has not been a regular part of their practices. However, as addiction treatment evolves and new medications become available, clinicians must become familiar with the specific mechanisms and physical effects of these drugs.

Some clinicians, especially those who have not recommended medications to their patients, may view them simply as a means to treat the symptoms of alcohol dependence without addressing the roots of the disease itself. However, by removing the physical reward from drinking or the craving for alcohol and other distressing symptoms that may accompany abstinence early in treatment, medications may allow patients to focus better on working with their counselors to develop skills and behaviors that will prevent future drinking. Thus, medications can complement and enhance the therapeutic process. It is important for clinicians to recognize that the use of medications is not a substitute for behavioral treatment but an enhancement designed to increase overall successful outcome.

Patients might also find the idea of using medications to reduce cravings or help with the physical aspects of addiction new and surprising. Therefore, clinicians are responsible for educating patients about how medications work, their potential benefits and side effects, and how they can be incorporated into counseling and therapy. In constructing a treatment plan, the clinician must assess the patient's readiness to change and whether medications will help patients in their efforts. For example, in the individual who resists the idea of medications but is willing to engage in psychosocial interventions, a discussion about potential medication benefits is warranted and should be approached carefully and with understanding, empathy, and respect for the patient's beliefs. Educating such individuals about medications may give them new insights, especially if they are having physical symptoms that could be ameliorated with medication. In such cases, it may be helpful to explain how medications may improve the patient's ability to devote his or her energies to what is being learned and discussed in counseling by lessening the craving and other physical changes that occur when dependent individuals curtail or stop drinking.

For individuals who have unsuccessfully used medications in the past, it is important to identify specifically the reasons for the difficulties; these may be wide-ranging, including side effects, cost, and adherence to treatment. When medication use is managed properly, however, many of these problems can be resolved, and medications might prove useful regardless of the intensity of care required. Medications may be used appropriately in a variety of situations, and an increasing number of medication options allows the clinician to better design therapeutic plans that best suit patients' particular needs.

In some cases, alcohol-dependent individuals might be receptive to the idea of using medication for treatment but not be interested in behavioral counseling. The clinician must explain to these patients that improvements in unhealthy drinking are less likely to be sustained if there is no accompanying behavior change, which would be fostered through counseling. Reasons for not wanting counseling need to be explored so that appropriate treatment interventions, such as Motivational Interviewing, can be created.

Although counselors do not prescribe medications, their treatment plans should include the rationale for the particular anti-addiction medicine(s) chosen for treatment. Certain medications may be better suited to the particular needs of individuals. For example, for patients who are still drinking and are having intense alcohol cravings, naltrexone is a logical choice, because its ability to block opioid receptors may reduce the rewards and reinforcing effects from drinking and help reduce craving. Acamprosate is indicated in individuals who have already ceased drinking and who may be experiencing some of the physical symptoms following withdrawal, such as anxiety, sleep disturbances, and alcohol cravings associated with a negative emotional state. Disulfiram is often prescribed for individuals for whom immediate abstinence is essential, because the adverse reaction produced when alcohol is consumed while taking disulfiram creates a powerful “incentive” to avoid drinking. Patients who have difficulty adhering to treatment because they are forgetful or are struggling with temptations to drink might benefit from the extended-release formulation of naltrexone, which requires a monthly injection as opposed to the daily dosing of other medications for alcohol dependence.

While each of these medications may improve treatment, there is no overwhelming evidence demonstrating additional benefits from using more than one at a time.5,6 Logical combinations of these medications need to be explored further in clinical trials.

Finally, it is important that medication use be monitored, progress assessed and measured, and the treatment plan modified as recovery proceeds. Counselors can help assess for common medication side effects and can support medication use by evaluating and encouraging adherence. The use of motivational enhancement strategies can support adherence. Engaging patients in a discussion of the effects of medication use will alert clinicians to any problems with the medication so that adherence is maximized and relapses can be avoided. Positive experiences with medications can be reinforced in therapy, so that adherence is maintained.

Patients' goals should be continually evaluated to determine if measurable progress is being made. In order for progress to be measured, it has to be defined. Progress can be patient-specific, and thus defined in different ways. For example, for some individuals progress might involve spending more time with family as opposed to drinking. It is necessary to adjust treatment plans depending on measurable treatment successes and shortfalls, and therefore the treatment plans, goals, and objectives will evolve based on patients' progress.

Adaptation of treatment plans may help retain patients in recovery over the long term.7 For example, varying the treatment intensity to match patients' stage in recovery and lowering the intensity when appropriate (when patients are not experiencing symptoms or relapsing) may allow clinicians to reserve more intense and potentially burdensome treatment for when patients' symptoms worsen. Patients may be more receptive to and engaged in treatment when it feels less onerous.7

Finding assistance with medication management

Integrating medication use into treatment requires a team that incorporates those responsible for counseling and support along with medication prescribers, such as physicians. Counselors who belong to organizations that do not endorse medication use or that lack the resources and staff to support medication use need to develop a plan to get adequate assistance with medication management, and will have to collaborate with other local treatment providers, addiction society chapters, or perhaps hospitals that have physicians trained to treat alcohol dependence. For example, the Web site of the American Society of Addiction Medicine (https://www.asam.org) can be used to find state ASAM chapters, which can be called for information about local providers. For states without chapters, the national organization office can be called directly.

Similarly, NAADAC, The Association for Addiction Professionals has state affiliates that can help provide information about treatment professionals, or the NAADAC national office can be contacted at https://www.naadac.org or (800) 548-0497. The manufacturers of the newer medications—acamprosate and extended-release naltrexone—also have referral networks of alcohol dependence treatment centers and providers. Constructing comprehensive treatment plans might require additional staff and referrals so that integrated care among various treatment providers can be done as seamlessly as possible.

Gerald Shulman, MA, MAC, FACATA, is the senior clinical and management executive trainer and consultant for Shulman and Associates. Correspondence may be sent to him at Shulman and Associates, 8658 Rolling Brook Lane, Jacksonville, FL 32256-9005; e-mail GDShulman@aol.com. His Web site is https://www.ShulmanSolutions.com.

References

1. Mee-Lee D, Shulman GD, Fishman M, et al. ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition—Revised (ASAM PPC-2R). Chevy Chase Md.:American Society of Addiction Medicine; 2001.
2. Miller SD, Mee-Lee D, Plum B, et al. Making treatment count: client-directed, outcome-informed clinical work with problem drinkers. Psychotherapy in Australia 2005; 11:42-56.
3. Connors GJ, Carroll KM, DiClemente CC, et al. The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. J Consult Clin Psychol 1997; 65:588-98.
4. Substance Abuse and Mental Health Services Administration. S.M.A.R.T. Treatment Planning. Retrieved from SAMHSA_NEWS.
5. Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA 2006; 295:2003-17.
6. Kiefer F, Jahn H, Tarnaske T, et al. Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind, placebo-controlled study. Arch Gen Psychiatry 2003; 60:92-9.
7. McKay JR. Continuing care in the treatment of addictive disorders. Curr Psychiatry Rep 2006; 8:355-62.

Supported by an educational grant from Alkermes, Inc., and Cephalon, Inc.