Have An Alcohol or Substance Abuse Problem? (Part 2)

Identifying as an “addict” or “alcoholic” is one end of the spectrum, but like most things in life, substance/alcohol abuse problems exist along a continuum from mild to severe and are influenced by a variety of factors (co-occurring disorders, socioeconomic status, past history of trauma, as well as genetic and neurobiological factors).

Read Part 1 for indications you might have a problem ->

Medications and Pharmacological Interventions– Modern science has enabled us to manage alcohol use with drugs like Naltrexone, as well as several others. Naltrexone in particular, blocks the intense pleasurable effects of alcohol for someone who derives strong reinforcement from drinking. As a result, the person feels satisfied with one or two drinks and doesn’t experience the desire for more.  The advantages of this approach is that it can be quite effective in reducing drink consumption, however the effects would be reversed as soon as you stopped taking the medication. Therefore, medications are best used in conjunction with other treatment approaches. Naltrexone, and similar medications on the market, can also target opiate cravings. The disadvantages are that they only exist for alcohol and opiate use and not other substances.

Cognitive Behavioral Therapy- With this approach you will work with a clinician who can help you understand your patterns of use and change them. You will learn what your triggering situations are (people, places, emotions, time of day); thoughts and belief patterns that lead to drinking/use; network of people who encourage use; maladaptive coping strategies; and craving patterns/urges. You will then learn effective tools, strategies, and new skills that help you make concrete changes (for instance how to turn down a drink or manage emotions more effectively). Typically, a short period of abstinence is recommend while individuals go through this treatment. At that point the person can decide whether they’d like to try controlled drinking/use, remain abstinent longer, or consider other options.  Cognitive behavioral therapy has a fairly strong research base for its effectiveness.

Moderation Management-  This support program offers both moderation and abstinence options for people who are concerned about their drinking/substance use.  Clients are able to select which option they prefer. The program focuses on self- management techniques, moderation, balance, and personal responsibility. For those who are focusing on moderation rather than abstinence, the program provides information on moderate drinking guidelines, drink monitoring exercises, and goal setting techniques.  The program is free and group members can attend whenever they like. There is some evidence base for Moderation Management which you can read on their website.

12- Step- Meetings (Alcoholics Anonymous, Marijuana Anonymous, Narcotics Anonymous)- A support group that began in the 1930’s by 2 alcoholics trying to quit drinking, Alcoholics Anonymous, is the oldest and most widespread of all treatment approaches.  Meetings exist in most cities throughout the country and in hundreds of different countries throughout the world. Meetings vary in sizes from very small to very large.  Perhaps it’s greatest advantages are the sense of community it provides to its members, as well as the availability of meetings.  AA is abstinence based and members work through the 12-Steps (i.e. admitting one’s powerlessness over alcohol, making amends to those one’s harmed) with a sponsor. People receive “chips” for various amounts of time sober.  The program is also free of charge.  The disadvantages to AA for many people are that complete abstinence is the goal, which may be unrealistic for some. There is also a spiritual component to the program that may conflict with people’s belief systems.  Unfortunately there is not a strong evidence base that shows AA is any more effective than some of the other treatments listed.

SMART Recovery (AKA Rational Recovery)- An alternative to AA, SMART Recovery is also a support group oriented program that is abstinence based. Participants learn tools for addiction recovery based on the latest scientific research and all types of addictions can be addressed (alcohol, substances, gambling, etc.). There is a cognitive behavioral component in which attendees learn to enhance motivation, cope with urges, manage thoughts, feelings, and behaviors, and live a balanced life. SMART Recovery differs from AA in that it is focused on science rather than the 12-Steps and does not have a spiritual component.

Outpatient Psychotherapy-  If you go this route make sure the psychologist, psychiatrist or marriage and family therapist has a specialization in addiction treatment and can help you make a well-informed recommendation about which treatment options are likely to be most effective for you.  Traditional talk therapy or supportive therapy where you just talk about your problems will not be effective.  If you work with someone on an outpatient basis make sure they use some form of cognitive behavioral therapy.

A good clinician will assess the severity of your substance abuse, psychological functioning, personal history, previous attempts at stopping, socioeconomic status, social support system, and goals/motivation for making changes.  Based on these factors, the clinician will develop a treatment plan that is best suited for you that likely involves multiple components (i.e. cognitive behavioral therapy as well as medication or moderation management). The treatment plan should also address any co-occurring psychiatric issues that are present.  The advantages of working with someone individually is that you will receive highly personalized treatment, work on multiple issues that are interrelated, build a strong rapport with a supportive person, and gain a deeper level of insight/understanding on your issues.

Inpatient Treatment Facilities– For some people working with a psychologist on an outpatient basis who specializes in addiction, or attending any of the aforementioned programs is not enough.  If your drinking or drug use is chronic or previous less intensive approaches at moderation or abstinence have failed, this might be your best option.  Similarly, if you have developed a tolerance to alcohol or other drugs and withdrawal symptoms are likely, this may be a necessary step.  Last, if everyone in your support system uses and/or drinks and it’s very difficult to resist the temptation they provide, creating some time for you to get away and focus on yourself is probably a good idea. Most inpatient treatment programs range from a week to over a month, and provide intensive psychotherapy and addiction treatment. There are many facilities around so before you make your decision inquire about their treatment approach and it’s success rate (are they 12 step based only or do they offer other evidence based treatments). The disadvantages of going to an inpatient facility are that they can be expensive and not all insurance companies cover the costs of the programs. They also involve taking time away from your day- to- day life. In the end however, you will have around the clock support, attention, and time to manage intensive cravings and urges until they subside.

One final note, we recommend moderation management and controlled recreational use only for alcohol and marijuana, and for those with mild to moderate patterns.  For harder drugs like cocaine, methamphetamines, and opiates, we recommend abstinence due to these substances hazardous health consequences with just one use.

Recognizing patterns and behaviors that aren’t working for you, and then changing them is never easy.  Our brains are hardwired to do the same things over and over again.  In some instances, it may be possible for alcohol or substance abuse issues to resolve on their own, but with the right interventions things are more likely to change.  There is always a payoff to self -reflection and I want to remind you that in the end we are always better off for it.  If one approach or attempt doesn’t work the first time around, learn from it, and keep going until you do find what works.

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Dr. Liana Georgoulis