When your child needs substance abuse treatment


It's hard for most parents to believe that their child might be caught up in substance abuse and in need of professional help. Don't feel bad if you didn't see the warning signs until your child was in trouble or until someone told you about a drug problem in your family. When most parents find out about their child's drug abuse, they feel shocked and stunned and wonder where they went wrong.
 

Many children and teens feel great pressure to try alcohol, tobacco, and drugs (ATD). They are flooded with pro-use messages from their friends; from alcohol and tobacco advertising and marketing; and from movies, music, music videos, and Web sites that appeal to youth. Parents often have less time to spend with their equally busy kids and fewer chances to keep track of their activities, friendships, and other influences. Parents feel like they are not ready to guide children on serious matters like alcohol and drug abuse.

Try not to blame yourself or your child if he has a substance abuse problem. The important thing is to act now to find the best available services to help your child stop using drugs and alcohol and begin building a drug-free future.

Your child's school may suggest a good substance abuse treatment program. If not, the school district is likely to have a substance abuse prevention and counseling program. Contact them for help. Local substance abuse or antidrug coalitions also can refer you to treatment services. To find a coalition in your neighborhood, check out http://www.helpyourcommunity.org/. Your county's health department probably has substance abuse services and is another good source for information. The county agency may be called "alcohol and drug programs" or "behavioral health" or may be within a "mental health services" division. A call to the county health agency's general information number should point you in the right direction.

The Frequently Asked Questions page at http://findtreatment.samhsa.gov/faq.htm will bring you to the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Substance Abuse Treatment Facility Locator. The site includes a quick search feature to help you find details about substance abuse treatment programs in your area.

Unfortunately, the demand for services to meet the treatment needs of teens and children is greater than the treatment options available. So, there are a few questions you should ask of any program before placing your child in their care:

1. How does the program meet the needs of people under age 18?
2. How does the program assess a teen's problems?
3. Does the program offer medication as part of the treatment plan, if needed?
4. How does the program review/update its treatment plan in light of a client's progress?
5. How is the family part of the treatment experience and process?
6. What does the program do to help children stay in treatment?
7. What are the staff's qualifications? Is the program run by State-accredited, licensed, or trained professionals? What clinical supervision is given?
8. Is the facility clean, organized, and well-run?
9. Does the program encompass the full range of needs of the child (medical, including infectious diseases; psychological, including co-occurring mental illness; social; vocational; legal; etc.)?
10. Does the treatment program also address sexual orientation and physical disabilities as well as provide age, gender, and culturally appropriate treatment services?
11. Does the program offer counseling (individual or group) and other behavioral therapies to enhance the child's ability to function in the family/community? Are single-sex groups, as well as mixed groups, offered? Are there male and female counselors?
12. What followup care is given after treatment is over? Does the program employ strategies to engage and keep the child in longer-term treatment, increasing the likelihood of success?
13. What evidence is there to show that the program works?
14. What are all of the costs involved in enrolling a child in the program? What types of insurance coverage are allowed? Are "scholarships" or sliding-scale fees given?

As with any illness or medical problem, early intervention and treatment of your child's substance abuse raises the chances of successful results. The sooner your child gets help, the less harm her drug or alcohol problem may cause and the better her chances are of developing a healthy, safe, and drug-free lifestyle. With your encouragement and support and an effective treatment plan, what is now a painful family experience can become a positive step toward a happy and fulfilling future.

You Can Help Your Child Make Healthy Choices!

Talk With Your Child-It's important to establish and maintain good communication with your child. Get into the habit of talking with your child every day.

Get Involved-It really can make a difference when you get involved in your child's life. Young people are much less likely to have mental health and substance use problems when they have positive activities to do and when caring adults are involved in their lives.

Set Rules-Make clear, sensible rules for your child and enforce them with consistency and appropriate consequences.

Be a Good Role Model-Set a good example for your child. Think about what you say and how you act in front of him.

Integrating pharmacotherapy with treatment planning for alcohol dependence. 

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 non-prescribers 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 (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 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.