Assessment and Treatment of Substance Use Disorders

Andrew J. Saxon

James P. Robinson

Mark D. Sullivan

This chapter on assessment and treatment of substance use disorders provides guidance, particularly for practitioners interested in pain medicine, on how various forms of substance use disorders are diagnosed and managed clinically. Because detection and management of opioid use disorder poses a major concern for physicians using opioids to treat patients, and because diagnosis of opioid use disorder in this context is often confounded by pain issues, the chapter focuses special attention on this complex clinical conundrum. More specifically, the chapter focuses on patients with chronic nonmalignant pain (CNMP) because issues related to opioid use disorder are more vexing in these patients than in patients with cancer or other lifethreatening illnesses.

Various surveys indicate that individuals with chronic pain disorders are more likely to have substance use disorders than are individuals in the general population,¹^,² and individuals with substance use disorders also have high rates of pain disorders.³ Therefore, practitioners treating pain disorders are likely to encounter patients with substance use disorders and will need to know how to screen for and recognize these disorders, diagnose these disorders, make appropriate referrals for and/or treat these disorders, monitor for these disorders during ongoing pain treatment, and manage therapy for chronic pain in the context of these disorders.

The first section of the chapter presents the assessment and treatment of all major forms of substance use disorders from the perspective of addiction medicine. The second section focuses on assessment and treatment of opioid use disorder from the perspective of the pain specialist.

Assessment and Treatment of Substance Use Disorders—Addiction Medicine Perspective

The panoply of substance-related disorders includes intoxication, withdrawal, substance use disorder (otherwise known as addiction), and substance induced psychiatric disorders (e.g., psychosis, mood disturbance, or anxiety caused directly by the use of the substance). Substance use disorders occur with a variety of commonly used substances such as alcohol, cannabis, cocaine, opioids, sedative/hypnotics, stimulants like amphetamines and methylphenidate, inhalants, psychedelic agents, and tobacco. A standardized set of criteria characterizing these disorders is provided in the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5).⁴ Intoxication and withdrawal obviously differ by substance and can generally be diagnosed through history and physical examination. The criteria for substance use disorder which will be covered in greater detail in the following text are identical across substances.

What is currently termed a substance use disorder in DSM-5 was known as either substance abuse or dependence in prior versions of the DSM, with abuse being considered a milder form of the disorder. The use of the term dependence generated some confusion and controversy. In contrast to a commonly held conception of “dependence” as notating purely physiologic changes that occur in response to repeated exposure to a substance, in prior versions of the DSM, “dependence” referred to a syndrome of physiologic signs and symptoms combined with an array of behavioral disturbances. Prior to the advent of DSM-5, some suggested that the phrase “substance dependence” referring to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., DSM-IV-TR) syndrome be replaced with the term addiction to avoid confusion between purely physiologic dependence and the syndrome of substance dependence.⁵ Others felt that the term addiction has negative connotations leading to stigmatization. A compromise was settled on with DSM-5 using the term substance use disorder. It is commonly understood that the terms addiction and substance use disorder are essentially synonymous and interchangeable.

SCREENING AND RECOGNITION

Clearly, some initial evidence must arise through screening to suggest that a patient has a substance use disorder to trigger a thorough diagnostic assessment. In many cases, screening and diagnostic evaluation may overlap. The idea of “universal precautions” in pain medicine has been advanced as one way to detect potential substance use problems in all pain patients, so there may be some value in routine use of some or all of these screening procedures.⁶ However, it is often too time-consuming and cumbersome to perform them in primary care, and there is no strong evidence that universal precautions or routine screening leads to better outcomes.

History

Generally, a thorough history of substance use obtained through a matter-of-fact, nonjudgmental interviewing style will provide a great deal of information or even a formal diagnosis. Most patients are not aware of guidelines for safe quantities of alcohol consumption and will readily divulge the amount of their drinking. Many patients are more reluctant to discuss use of illicit substances, but some will freely admit to such use if they do not fear sanctions or punishment. Oftentimes, this openness is more likely to occur during initial intake. Patients may be less forthright during the course of treatment if they believe they have something to lose by admitting to use. If time allows, it is worth asking explicitly about frequency and quantity of use for each class of substance along with route of administration. It is also quite important to ask about any history of current and past problematic substance use, as such problematic use is known to increase the risk of recurrence in the context of pain management. It is useful to know what types of substance use disorders treatment, if any, have been helpful for the patient in the past.

Recommended safe quantities of alcohol use consist of no more than four standard drinks per day (or more than 14 total per week) for men and three standard drinks (or more than 7 total per week) for women.⁷ The recommended quantities are less for women because women tend to have less total body water and thus a lower volume of distribution for alcohol.⁸ Quantities of different forms of alcohol that define a standard drink are listed in Table 91.1. If patients acknowledge regularly consuming more than the recommended amounts or describe heavy drinking such as five or more drinks on one occasion for men or four or more for women, a more thorough diagnostic evaluation for alcohol use disorder should be pursued.

TABLE 91.1 Quantities of Alcohol that Define a Standard Drink (14 g Pure Alcohol)

Beverage	Percent Alcohol	Quantity in Standard Drink (in Fluid Ounces)
Beer	5%	12
Malt liquor	7%	8.5
Table wine	12%	5
Fortified wine	17%	3.5
Liqueur	24%	2.5
Brandy	40%	1.5
Spirits (gin, vodka, whiskey)	40%	1.5

For illicit substances, any suggestion of more than occasional recreational use of marijuana should prompt a more thorough diagnostic evaluation. It is also important to look for tobacco use disorder, as this disorder has been associated with increased risk of opioid misuse in a number of studies.¹^,⁹

Physical Examination

Signs of possible substance use problems evident on physical exam include hypertension (common with excessive alcohol use), track marks indicative of recent or past injection drug use, pupillary constriction or dilation, inflamed nasal turbinates from intranasal substance insufflation, wheezes or rhonchi on lung exam from substance smoking, enlarged, tender liver from excessive alcohol use, other substance toxicity or hepatitis, or any stigmata of excessive alcohol use such as flushed facies, spider angiomas, palmar erythema, etc. Any of these findings should trigger further screening and possible thorough diagnostic evaluation.

Laboratory

Routine blood work can provide an indication of excessive alcohol use. Suggestive findings include elevations in liver transaminases or macrocytic, hyperchromic red blood cells related to alcohol’s interference with folate absorption, and subsequent folate deficiency. Positive serologies for past or current hepatitis B or C infection or HIV infection would raise concerns about a substance use-related mode of transmission.

In addition, specific laboratory testing to detect presence of substances in body fluids offers a convenient component of screening. Typically, urine is tested,¹⁰ although tests can also be readily performed in oral fluid or blood.¹¹^,¹² Substances that have been used are likely to remain present in urine for a longer period than they will in other body fluids (Table 91.2). For urine testing, a screening test is typically performed via immunoassay. When needed, confirmatory tests using high-performance liquid chromatography/mass spectrometry or gas chromatography/mass spectrometry can be ordered. It is important to note that the routine urine assay for opioids does not detect oxycodone, methadone, buprenorphine, or fentanyl which each requires a specific screening test. Heroin can only be detected shortly after use if its intermediate metabolite, 6-monoacetylmorphine, is present. Subsequently, 6-monoacetylmorphine is rapidly metabolized to morphine. If morphine appears in a urine toxicology specimen, it could represent either pharmaceutical morphine use or heroin use. It is difficult to detect alcohol in urine, blood, oral fluid, or breath unless the use has been quite recent. However, the alcohol metabolites, ethyl glucuronide or ethyl sulfate, indicating recent alcohol use can be detected in urine, blood, or hair.¹³

Self-report Questionnaires

A number of self-report questionnaires have been designed to help in screening for substance use disorders, and these can be utilized prior to, concurrent with, or subsequent to the history, physical, and laboratory evaluation to help determine whether a patient warrants more thorough diagnostic evaluation. Although the instruments described in the following text have definite utility in primary care and general populations as well as selected samples such as psychiatric patients, they have not been tested in pain patients.

TABLE 91.2 Drug Detection Times in Urine and Drug Plasma Half-lives

Drug		Detection Time in Urine (Based on Standard Cutoff Values)	Plasma Half-life
Amphetamine		2-3 d	12 h
Cocaine metabolite (Benzoylecgonine)		2-3 d	7.5 h
Opioids
	Morphine glucuronide	2 d	7.5 h
	Codeine glucuronide	3 d	12 h
	Heroin metabolite (6-monoacetylmorphine)	2-4 h	20 min
	Methadone	3 d single use 7-9 d maintenance dosing	24 h
	Oxycodone	2 d	5 h
	Hydromorphone	1-2 d	2.5 h
	Hydrocodone	1-2 d	4 h
Barbiturates
	Short acting	1 d	25 h
	Intermediate acting	2-3 d	38 h
	Long acting	≥16 d	100 h
Benzodiazepines
	Short acting	1 d	1.5 h
	Intermediate acting	2-4 d	10 h
	Long acting	≥7 d	48 h
Cannabis single use		3 d	20 h
Cannabis chronic use		≥30 d	20 h

In screening for alcohol use disorders, the currently most frequently used instruments are the Alcohol Use Disorders Identification Test (AUDIT)¹⁴ and the Michigan Alcoholism Screening Test (MAST).¹⁵ The AUDIT has 10 items related to quantity and frequency of alcohol consumption and to maladaptive behaviors associated with alcohol use and can be completed in about 5 minutes. Each item is scored 0 to 4. A score of 8 or more for men under age 60 years or 4 or more for women or men over age 60 years are considered positive screens indicative of need for further assessment. A shorter version of the AUDIT, the AUDIT-C, which asks only 3 questions related to consumption has also been validated as a screening instrument in primary care settings.¹⁶ The MAST contains 25 questions and focuses more on problem behaviors associated with alcohol use. Each item counts for 1 point, and a score of 6 or more indicates a positive screen with need for further assessment. There are shorter versions of the MAST which also appear to function as adequate screening instruments.

In the context of managing pain patients where urine toxicology should be readily available, self-report instruments to screen for drug use problems are probably less useful than a positive urine toxicology. However, if use of a self-report screening instrument is desired, a commonly used instrument is the Drug Abuse Screening Test (DAST).¹⁷ The DAST is based on the MAST and has 28 items concerning both intensity and frequency of drug use and problematic behaviors associated with drug use. As with the MAST, each item counts for 1 point, and a score of 6 or more points to the needs for further assessment. Shorter versions of the DAST also exist.

A much briefer option to screen for a possible drug use disorder is the single item question, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” This single item performed as well as the DAST-10 at detecting a substance use disorder.¹⁸

One recently validated instrument that screens for all major substances is the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool, which is reasonably brief and can be self-administered.¹⁹

PRESCRIPTION DRUG MONITORING PROGRAM

Most states in the United States provide prescription drug monitoring programs (PDMPs). How they function and what the requirements are to access them vary widely from state to state. They do provide information on most controlled substance prescriptions that individual patients have obtained. Checking the PDMP can be very helpful in verifying the prescription medications that the patient is reporting via history.²⁰

DIAGNOSTIC ASSESSMENT

As noted earlier, criteria provided in DSM-5 represent the most standard way to make a diagnosis of a substance use disorder. At times, it proves fruitful to interview family members if the patient is not forthcoming.

Table 91.3 contains DSM-5 criteria for opioid use disorder as an example. The criteria for a substance use disorder are identical across all substances. To determine the presence or absence of the diagnosis, the interviewer should focus one by one in turn on each substance of potential relevance and systematically go over each of the criteria with the patient for each substance.

TABLE 91.3 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Diagnostic Criteria for Opioid Use Disorder

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring within a 12-mo period:

Opioids are often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
Craving, or a strong desire or urge to use opioids
Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home
Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids
Important social, occupational, or recreational activities are given up or reduced because of opioid use.
Recurrent use of opioids in situations in which it is physically hazardous
Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
Tolerance,^a as defined by either of the following:
1. A need for markedly increased amounts of opioids to achieve intoxication or desired effect
2. A markedly diminished effect with continued use of the same amount of opioid
Withdrawal^a as manifested by either of the following:
1. The characteristic opioid withdrawal syndrome
2. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

^aThis criterion is not considered to be met for those taking the substance solely under appropriate medical supervision.

Mild = 2-3 symptoms.

Moderate = 4-5 symptoms.

Severe = 6 or more symptoms.

There are 2 physiologic criteria, tolerance and withdrawal, and 9 behavioral criteria. Two or more of the 11 criteria must be present at any one time over a 12-month period to make the diagnosis. If 2 to 3 criteria are present, the disorder is classified as mild; if 4 to 5 are present, as moderate; and if 6 or more, as severe. The physiologic criteria are not considered to be met for individuals taking the substance under medical supervision. For example, a pain patient treated chronically with opioids who is taking them precisely as prescribed might display tolerance to the effects of opioids and withdrawal signs and symptoms if the medication is stopped, but in this situation, these two criteria would not be applied to the diagnosis of opioid use disorder. Similarly, this scenario could occur with an attention-deficit/hyperactivity disorder patient treated chronically with stimulants, or with an anxiety disorder patient treated chronically with benzodiazepines. Conversely, an individual might not have either tolerance or withdrawal but could have the DSM-5 defined substance use if he or she meets at least two of the behavioral criteria, although this scenario occurs rarely in clinical practice. Inspection of the criteria reveals that questions about each criterion are unlikely to be interpreted by patients as critical or threatening and unlikely to engender resistance or deception, particularly if posed in a matter-of-fact, nonjudgmental fashion. Although this procedure sounds time-consuming, it frequently can be accomplished in a matter of minutes for each substance of concern. As mentioned at the outset, the diagnosis of opioid use disorder in a patient with CNMP being treated with opioids may not be as straightforward as simple application of the DSM-5 criteria and is discussed in detail in the following text.

Diagnosis of a substance use disorder certainly should not preclude appropriate interventions for a pain problem and in rare instances, with appropriate monitoring and safeguards, may not categorically preclude opioid treatment of chronic pain.

Co-occurring Psychiatric Disorders

Mental health disorders frequently co-occur with substance use disorders.²¹^,²² It is likely that chronic pain patients who have substance use disorders will have another non-substancerelated co-occurring mental health disorder.²³ Oftentimes, co-occurring mental health and substance use disorders interact with negative synergy so that exacerbation of one disorder in turn exacerbates the other.²⁴ Thus, if a pain patient does have a substance use disorder, it is imperative to evaluate that patient for other co-occurring mental health disorders and provide appropriate clinical intervention (including pharmacotherapy and/or psychotherapy) for any that are diagnosed.

MONITORING DURING ONGOING PAIN TREATMENT

Even if a patient does not manifest a substance use disorder at the onset of chronic pain treatment, a disorder can certainly arise during the course of treatment. Maintaining vigilance for the development of a disorder involves both observation of the patient for behavioral evidence and routine monitoring techniques.⁶ Behaviors that may increase the index of suspicion include missing appointments, having medication shortages, failure to pay bills, or a markedly changed affect during appointments.

Depending on the setting and resources available, it may prove worthwhile to establish routine, monitoring procedures for all pain patients even in the absence of concern. This approach normalizes these procedures, allows patients to expect them, and creates structure that may actually help the patient to feel supported while removing any sense of stigma or accusation that may supervene if the procedures are applied only for cause. The procedures that will be utilized should be specified at the outset of treatment in a written treatment agreement.
One obvious routine monitoring procedure to consider is urine toxicology testing as described earlier.²⁵

Another potential procedure is unscheduled medication call backs. For this procedure, patients are telephoned and asked to return to the office within 24 hours with all their outstanding medication. When the patients come in, pill counts are performed to ensure that all expected outstanding medication is accounted for. It is also possible to obtain a urine toxicology specimen at that time.

TREATMENT AND/OR REFERRAL

Some general comments about treatment and referral will be made, and then specific interventions for use disorders involving each particular class of substances will be outlined. Most physicians get virtually no training or experience in treatment of substance use disorders and, therefore, often feel helpless or hopeless in the face of these disorders. Although many patients with these disorders who do get treatment get it in specialized settings that operate in parallel to and oftentimes outside of mainstream medicine, many patients will refuse a referral to such settings, and a growing body of literature supports the efficacy of physician intervention as a reasonable first attempt at treating these disorders.

Brief Interventions

Brief office interventions conducted by physicians have demonstrated efficacy in reducing alcohol consumption for patients with problematic alcohol use that does not rise to the level of an alcohol use disorder but very limited if any benefit for alcohol use disorder.²⁶^,²⁷ Motivational interventions (see following text) which can be incorporated into brief office interventions have demonstrated modest efficacy in nonalcohol substance use disorders.²⁸

Brief interventions should be delivered in a manner that is matter-of-fact, nonjudgmental, supportive, and empathic and definitely not in a manner that is confrontational. The first step consists of stating concern about the patient’s level of alcohol use (or any level of illicit drug use). It is helpful to give the patient direct examples from his or her medical record including bothersome symptoms, physical findings, specific diseases, or lab abnormalities. The next step involves giving direct advice to cut down (or quit) the substance use along with an offer to help. If the patient is not receptive to this advice, and the situation is not emergent, the physician can encourage him or her to consider it carefully and reflect on why he or she considers ongoing use to be a reasonable course of action. A follow-up can be arranged for further discussion.

If the patient appears receptive to advice to cut down or quit, the physician helps the patient to establish a specific goal to cut down or abstain (for a use disorder). Also, the physician provides explicit behavioral suggestions such as avoiding acquaintances who use, avoiding places where use has previously occurred, or seeking social support for quitting, including attending mutual-help groups such as Alcoholics Anonymous or Narcotics Anonymous. A follow-up appointment should be scheduled to monitor progress.

If the patient has alcohol use disorder and is willing to try for abstinence, the brief intervention could be combined with prescription of an appropriate alcohol treatment medication as described in the following text. If the patient has developed opioid use disorder, the brief intervention could be combined with a recommendation to try buprenorphine also described in the following text. If the pain physician treating the patient has a federal waiver to prescribe buprenorphine, arrangements could be made to stop any opioid analgesic the patient may currently be taking and make a switch to buprenorphine.

Specialty Substance Use Disorders Treatment

If a referral to a specialized substance use disorders treatment provider is needed, the referral could be made to an individual practitioner, another physician, psychologist, social worker, or chemical dependency counselor who specializes in substance use disorders treatment and could work with the patient in a private office setting using one or more of the psychotherapeutic or behavioral interventions detailed in the following text. Frequently, the referral will be made to an addiction treatment or substance use disorders program or agency. The American Society of Addiction Medicine publishes Patient Placement Criteria that can aid in determining what level of addiction treatment is appropriate for a given patient. These criteria have not, however, been fully scientifically validated and are based largely on expert opinion.²⁹^,³⁰

Medically Supervised Withdrawal

Some patients, who manifest withdrawal when stopping their substance use, may need medically supervised withdrawal (also known as detoxification) to stop the substance safely and engage in treatment. The most common substances which require supervised withdrawal are alcohol, sedative-hypnotics, and opioids, although patients may have very unpleasant withdrawal symptoms from marijuana, cocaine, or amphetamines and need some support and monitoring. Medically supervised withdrawal can be accomplished on an outpatient or inpatient basis depending on the severity of the withdrawal. Clearly, alcohol or sedative-hypnotic withdrawal can be life-threatening. Usually, benzodiazepines are prescribed over several days in tapering doses.³¹ Supervised opioid withdrawal for physiologic dependence on opioids can be accomplished using methadone in a licensed treatment program³² (see the following text) or with buprenorphine³³ by appropriately qualified physicians. Alternatively, the α₂-adrenergic agonist, clonidine, can be prescribed to attenuate opioid withdrawal signs and symptoms and tapered over several days.³⁴ Some paradigms, known as ultrarapid opioid withdrawal, have been developed whereby opioid withdrawal is precipitated with an opioid antagonist such as naloxone or naltrexone under sedation or general anesthesia to complete the withdrawal in a brief period of time. These rapid procedures have no better outcomes than more gradual withdrawal but do have more adverse events such as pulmonary problems and psychiatric instability so they are not recommended.³⁵ It is very important to understand that medically supervised withdrawal (detoxification) alone does not constitute treatment. If medically supervised withdrawal is not immediately followed by more definitive substance use disorders treatment, relapse is almost universal.

Opioid Maintenance Treatment

Many patients with primary opioid use disorder do not want to undergo withdrawal or have tried it previously with subsequent relapse. These patients might be referred to a federally licensed opioid treatment program.³⁶ These programs provide opioid maintenance therapy with either methadone or buprenorphine. Because these medications have long half-lives, they can prevent the emergence of opioid withdrawal when taken on a once a day basis. (More detail on the clinical use of these medications for the treatment of opioid use disorder is provided in the following text.) The structure of the program is largely dictated by federal and state regulations. Patients must have a minimum of a 1-year history of opioid use disorder. In the early stages of treatment, patients must come to the clinic daily for observed doses of medication with take home doses of medication for weekend days when the clinic is closed. The maximum allowed first dose of methadone is 30 mg with subsequent gradual dose escalation to an optimally therapeutic dosage. A physical examination and basic laboratory tests are required as is periodic
urine toxicology testing. Regular counseling visits are delivered as needed. As patients stabilize in treatment, as evidenced by regular attendance at dosing visits and other appointments, remaining on a stable dose of medication, and ceasing illicit substance use as demonstrated by drug-free toxicology specimens, take home doses of medication become available so that patients do not have to attend clinic every day. After 2 years of continuous treatment, stable patients on methadone may receive up to a maximum of 1 month’s take home doses. Patients treated with buprenorphine in these settings can gain access to take home doses whenever they meet criteria for stability without regard to time in treatment. Opioid maintenance treatment has exceptionally good outcomes not only in terms of reducing illicit opioid use but also in terms of reducing other substance use, reducing mortality and morbidity, reducing criminal justice involvement, and improving employment.³⁷^,³⁸ It is considered to be as cost-effective as other potential life saving treatments such as coronary bypass surgery or renal dialysis.³⁹ All physicians are permitted to prescribe methadone for pain management, but only specially licensed facilities can order and dispense methadone specifically for opioid use disorder. Prescription of methadone for pain in patients with signs of opioid use disorder has obvious inherent risks and should be undertaken with careful monitoring precautions in place.

Intensive Outpatient Treatment

For patients who do not have opioid use disorder or who have opioid use disorder but decline maintenance therapy and have completed withdrawal, intensive outpatient treatment is often employed. This type of treatment is generally abstinence-based in that it emphasizes the goal of total abstinence from alcohol and all illicit substances. Some programs would accept pain patients on prescribed opioid therapy if the patient has a goal of abstinence from other substance use. Intensive outpatient treatment involves behavioral interventions usually via a group format with several meetings per week over a 4- to 12-week period so that patients receive up to 72 or more hours of total treatment.⁴⁰ Frequent urine toxicology testing is also typically performed. The therapeutic content of the group sessions varies but often includes one or more of the types of behavioral interventions described in the following text. Attendance at mutual help groups such as Alcoholics Anonymous is strongly encouraged. Not surprisingly, patients who complete these programs have better outcomes than those who drop out. Depending on the setting and patient characteristics, the dropout rate can be substantial.

Inpatient Treatment

For patients who fail outpatient treatment and who can obtain funding for it, inpatient treatment is an option. Inpatient treatment could be as brief as a few days⁴¹ but frequently lasts 28 days and can be extended for many months in a model known as a therapeutic community⁴² for patients who have severe, intractable substance use disorders that do not respond to any other interventions. Ongoing outpatient treatment subsequent to completion of inpatient treatment is recommended. Inpatient treatment, like intensive outpatient treatment, is almost always abstinence-based. Many short-term inpatient programs would accept pain patients on opioid therapy if the patients committed to abstinence from other substances. Most therapeutic communities would not accept patients receiving opioid therapy even for pain. The content of the care in inpatient treatment does not differ substantially from the content delivered in intensive outpatient treatment, but the inpatient setting provides a controlled environment that minimizes the risk of relapse and can compress more hours of actual treatment into a shorter overall time frame.⁴³ In the aggregate, it appears that the quantity or “dose” of behavioral treatment received rather than the setting in which it occurs serves as the key mediator of outcome.

Specific Behavioral Treatments

Numerous types of behavioral interventions are used to treat substance use disorders, and many have been empirically validated. Mastery of specific techniques often requires considerable training and practice. Most studies comparing various behavioral intervention techniques find, as with setting, that the specific technique is less important than the total amount of behavioral intervention received. Many practitioners do not deliver the specific interventions in their pure form. In addition to the amount of intervention received, other important mediators of success are the skill of the specific therapist and the therapeutic alliance achieved between the therapist and patient regardless of what technique is used.⁴⁴ To impart at least passing knowledge of the names and basic philosophies of the more common techniques, brief descriptions are provided.

Motivational Interviewing

Motivational interviewing is a directive, patient-centered counseling style for eliciting behavior change by helping patients explore and resolve ambivalence. Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal using the following techniques.⁴⁵

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