CHAPTER 4EARLY INTERVENTION, TREATMENT, AND MANAGEMENT OF SUBSTANCE USE DISORDERS

Chapter 4 Preview

A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.² Substance use disorders range in severity, duration, and complexity from mild to severe. In 2015, 20.8 million people aged 12 or older met criteria for a substance use disorder. While historically the great majority of treatment has occurred in specialty substance use disorder treatment programs with little involvement by primary or general health care, a shift is occurring toward the delivery of treatment services in general health care practice. For those with mild to moderate substance use disorders, treatment through the general health care system may be sufficient, while those with severe substance use disorders (addiction) may require specialty treatment.

The good news is that a spectrum of effective strategies and services are available to identify, treat, and manage substance use problems and substance use disorders. Research shows that the most effective way to help someone with a substance use problem who may be at risk for developing a substance use disorder is to intervene early, before the condition can progress. With this recognition, screening for substance misuse is increasingly being provided in general health care settings, so that emerging problems can be detected and early intervention provided if necessary. The addition of services to address substance use problems and disorders in mainstream health care has extended the continuum of care, and includes a range of effective, evidence-based medications, behavioral therapies, and supportive services. However, a number of barriers have limited the widespread adoption of these services, including lack of resources, insufficient training, and workforce shortages.⁵ This is particularly true for the treatment of those with co-occurring substance use and physical or mental disorders.^6,7

This chapter provides an overview of the scientific evidence supporting the effectiveness of treatment interventions, therapies, services, and medications available to identify, treat, and manage substance use problems and disorders.

Continuum of Treatment Services

Substance use disorders typically emerge during adolescence and often (but not always) progress in severity and complexity with continued substance misuse.^9,10 Currently, substance use disorders are classified diagnostically into three severity categories: mild, moderate, and severe.²

Substance use disorder treatment is designed to help individuals stop or reduce harmful substance misuse, improve their health and social function, and manage their risk for relapse. In this regard, substance use disorder treatment is effective and has a positive economic impact. Research shows that treatment also improves individuals' productivity,¹¹ health,^11,12 and overall quality of life.^13-15 In addition, studies show that every dollar spent on substance use disorder treatment saves $4 in health care costs and $7 in criminal justice costs.¹¹

Mild substance use disorders can be identified quickly and reliably in many medical and social settings. These common but less severe disorders often respond to brief motivational interventions and/or supportive monitoring, referred to as guided self-change.¹⁶ In contrast, severe, complex, and chronic substance use disorders often require specialty substance use disorder treatment and continued post-treatment support to achieve full remission and recovery. To address the spectrum of substance use problems and disorders, a continuum of care provides individuals an array of service options based on need, including prevention, early intervention, treatment, and recovery support (Figure 4.1). Traditionally, the vast majority of treatment for substance use disorders has been provided in specialty substance use disorder treatment programs, and these programs vary substantially in their clinical objectives and in the frequency, intensity, and setting of care delivery.

Figure 4.1

Substance Use Status and Substance Use Care Continuum.

This chapter describes the early intervention and treatment components of the continuum of care, the major behavioral, pharmacological, and service components of care, services available, and emerging treatment technologies:

• Early Intervention, for addressing substance misuse problems or mild disorders and helping to prevent more severe substance use disorders.
• Treatment engagement and harm reduction interventions, for individuals who have a substance use disorder but who may not be ready to enter treatment, help engage individuals in treatment and reduce the risks and harms associated with substance misuse.
• Substance use disorder treatment, an individualized set of evidence-based clinical services designed to improve health and function, including medications and behavioral therapies.
• Emerging treatment technologies are increasingly being used to support the assessment, treatment, and maintenance of continuing contact with individuals with substance use disorders.

Early Intervention: Identifying and Engaging Individuals At Risk for Substance Misuse and Substance Use Disorders

Early intervention services can be provided in a variety of settings (e.g., school clinics, primary care offices, mental health clinics) to people who have problematic use or mild substance use disorders.¹⁷ These services are usually provided when an individual presents for another medical condition or social service need and is not seeking treatment for a substance use disorder. The goals of early intervention are to reduce the harms associated with substance misuse, to reduce risk behaviors before they lead to injury,¹⁸ to improve health and social function, and to prevent progression to a disorder and subsequent need for specialty substances use disorder services.^17,18 Early intervention consists of providing information about substance use risks, normal or safe levels of use, and strategies to quit or cut down on use and use-related risk behaviors, and facilitating patient initiation and engagement in treatment when needed. Early intervention services may be considered the bridge between prevention and treatment services. For individuals with more serious substance misuse, intervention in these settings can serve as a mechanism to engage them into treatment.¹⁷

Components of Early Intervention

One structured approach to delivering early intervention to people showing signs of substance misuse and/or early signs of a substance use disorder is through screening and brief intervention (SBI).²²

Research has shown that several methods of SBI are effective in decreasing “at-risk” substance use and that they work for a variety of populations and in a variety of health care settings.^22,23 As mentioned earlier, this research has demonstrated positive effects for reducing alcohol use;^24,25 the research with SBI among those with other substance use disorders has shown mixed results.^26-29

In addition, research shows that SBI can be cost-effective. For example, a randomized study compared SBI to screening alone for alcohol and drug use disorders among patients covered by Medicaid in eight emergency medicine clinics in the State of Washington. A year later, investigators compared total Medicaid expenditures between the two groups and found that the costs per member, per month for the SBI group were $185 to $192 lower than the costs for the screening-only group. This added up to a savings of more than $2,200 per patient in one year.³⁰

FOR MORE ON THIS TOPIC

See Chapter 6 - Health Care Systems and Substance Use Disorders.

SBI: Screening

Ideally, substance misuse screening should occur for all individuals who present in health care settings, including primary, urgent, psychiatric, and emergency care. Professional organizations, including the American College of Obstetricians and Gynecologists, the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics recommend universal and ongoing screening for substance use and mental health issues for adults and adolescents.^31-36 Such screening practices can help identify the severity of the individual's substance use and whether substance use disorder treatment may be necessary.

Within these contexts, substance misuse can be reliably identified through dialogue, observation, medical tests, and screening instruments.³⁷ Several validated screening instruments have been developed to help non-specialty providers identify individuals who may have, or be at risk for, a substance use disorder.

Table 4.1 provides examples of available substance use screening tools, how they are used, and for which age groups. In addition to these tools, single-item screens for presence of drug use (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) and for alcohol use (“How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women) have been validated and shown in primary care to accurately identify individuals at risk for or experiencing a substance use disorder.^38-42

Table 4.1

Evidence-Based Screening Tools for Substance Use.

SBI: Brief Interventions

Brief interventions (or brief advice) range from informal counseling to structured therapies. They often include feedback to the individual about their level of use relative to safe limits, as well as advice to aid the individual in decision-making.¹⁷

Motivational interviewing (MI) is a client-centered counseling style that addresses a person's ambivalence to change. A counselor uses a conversational approach to help their client discover their interest in changing their substance using behavior. The counselor asks the client to express their desire for change and any ambivalence they might have and then begins to work with the client on a plan to change their behavior and to make a commitment to the change process. The main purpose of MI is to examine and resolve ambivalence, and the counselor is intentionally directive in pursuing this goal.⁴⁴ It is effective in reducing the substance misuse of patients who come to medical settings for other health-related conditions.⁴⁵ In these settings, individuals who receive MI are more likely to adhere to a treatment plan and, subsequently, to have better outcomes.^24,46

SAMHSA SBIRT Education

SAMHSA offers free SBIRT Continuing Medical Education and Continuing Education courses for providers.

Adding Referral to Treatment When Necessary

When an individual's substance use problem meets criteria for a substance use disorder, and/or when brief interventions do not produce change, it may be necessary to motivate the patient to engage in specialized treatment. This is called Screening, Brief Intervention, and Referral to Treatment (SBIRT). In such cases, the care provider makes a referral for a clinical assessment followed by a clinical treatment plan developed with the individual that is tailored to meet the person's needs.⁴⁷ Effective referral processes should incorporate strategies to motivate patients to accept the referral. Although the screening and brief intervention components of SBIRT are the same as SBI, referral to treatment helps the individual access, select, and navigate barriers to substance use disorder treatment.

The literature on the effectiveness of drug-focused brief intervention in primary care and emergency departments is less clear, with some studies finding no improvements among those receiving brief interventions.^48,49 However, at least one study found significant reductions in subsequent drug use.⁵⁰ Even if brief interventions are not found to be sufficient to address patients' drug use disorders, general health care settings still have an important role to play in addressing drug use disorders, by providing medication-assisted treatment (MAT), providing more robust monitoring and care coordination, and actively promoting engagement in specialty substance use disorder treatment.

Trials evaluating different types of screening and brief interventions for drug use in a range of settings and on a range of patient characteristics are lacking. Recently, efforts have been made to adapt SBIRT for adolescents and for all groups with substance use disorders.^51,52 The results of preliminary studies are promising,^20,53 but gaps in knowledge about SBIRT for adolescents still need to be filled.⁵⁴

Treatment Engagement: Reaching and Reducing Harm Among Those Who Need Treatment

Principles of Effective Treatment and Treatment Planning

Principles and Goals of Treatment

Treatment can occur in a variety of settings but most treatment for substance use disorders has traditionally been provided in specialty substance use disorder treatment programs. For this reason, the majority of research has been performed within these specialty settings.⁹¹ The following sections describe what is known from this research about the processes, stages of, and outcomes from traditional substance use disorder treatment programs.

The National Institute on Drug Abuse (NIDA) has detailed the evidence-based principles of effective treatment for adults and adolescents with substance use disorders that apply regardless of the particular setting of care or type of substance use disorder treatment program (Table 4.2).^85,92

Table 4.2

Principles of Effective Treatment for Substance Use Disorders.

The goals of substance use disorder treatment are similar to those of treatments for other serious, often chronic, illnesses: reduce the major symptoms of the illness, improve health and social function, and teach and motivate patients to monitor their condition and manage threats of relapse. Substance use disorder treatment can be provided in inpatient or outpatient settings, depending on the needs of the patient, and typically incorporates a combination of behavioral therapies, medications, and RSS. However, unlike treatments for most other medical illnesses, substance use disorder treatment has traditionally been provided in programs (both residential and outpatient) outside of the mainstream health care system. The intensity of the treatment regimens offered can vary substantially across program types. The American Society of Addiction Medicine (ASAM) has categorized these programs into “levels” of care to guide referral based on an individual patient's needs.^93-95

Despite differences in care delivery and differences in reimbursement, substance use disorder treatments have approximately the same rates of positive outcomes as treatment for other chronic illnesses. Relapse rates for substance use disorders (40 to 60 percent) are comparable to those for chronic diseases, such as diabetes (20 to 50 percent), hypertension (50 to 70 percent), and asthma (50 to 70 percent).¹²

KEY CONCEPT

Treatment varies depending on substance(s) used, severity of substance use disorder, comorbidities, and the individual's preferences.

Treatment typically includes medications and counseling as well as other social supports such as linkage to community recovery groups depending on an individual patient's needs and level of existing family and social support.

The general process of treatment planning and delivery for individuals with severe substance use disorders is described below, along with an explanation of the evidence-based therapies, medications, and RSS shown to be effective in treatment.

Treatment Planning

Assessment and Diagnosis

Among the first steps involved in substance use disorder treatment are assessment and diagnosis. The diagnosis of substance use disorders is based primarily on the results of a clinical interview. Several assessment instruments are available to help structure and elicit the information required to diagnose substance use disorders. The diagnosis of a substance use disorder is made by a trained professional based on 11 symptoms defined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These symptoms, which are generally related to loss of control over substance use,⁹⁶ are presented in Table 1.5² in Chapter 1. The number of diagnostic symptoms present defines the severity of the disorder, ranging from mild to severe (i.e., fewer than 2 symptoms = no disorder; 2 to 3 symptoms = mild disorder; 4 to 5 symptoms = moderate disorder; 6 or more symptoms = severe disorder).⁹⁷

FOR MORE ON THIS TOPIC

See Chapter 1 - Introduction and Overview.

Conducting a clinical assessment is essential to understanding the nature and severity of the patient's health and social problems that may have led to or resulted from the substance use. This assessment is important in determining the intensity of care that will be recommended and the composition of the treatment plan.⁹¹ Several validated assessment tools can provide information about an individual's substance use disorder. Table 4.3 gives a brief overview of some of the tools that are available.

Table 4.3

Detailed Information on Substance Use Disorder Assessment Tools.

Individualized Treatment Planning

After a formal assessment, the information is discussed with the patient to jointly develop a personalized treatment plan designed to address the patient's needs.^91,101 The treatment plan and goals should be person-centered and include strength-based approaches, or ones that draw upon an individual's strengths, resources, potential, and ability to recover, to keep the patient engaged in care. Individualized treatment plans should consider age, gender identity, race and ethnicity, language, health literacy, religion/spirituality, sexual orientation, culture, trauma history, and co-occurring physical and mental health problems. Such considerations are critical for understanding the individual and for tailoring the treatment to his or her specific needs. This increases the likelihood of successful treatment engagement and retention, and research shows that those who participate more fully in treatment typically have better outcomes.¹⁰² Throughout treatment, individuals should be periodically reassessed to determine response to treatment and to make any needed adjustments to the treatment plan.

Maintaining Treatment Engagement and Retention

Treatment plans should be personalized and include engagement and retention strategies to promote participation, motivation, and adherence to the plan.⁴⁷ Research has found that individuals who received proactive engagement services such as direct outreach and a specific follow-up plan are more likely to remain engaged in services throughout the treatment process.^47,103,104

Treatment providers can improve engagement and retention in programs by building a strong therapeutic alliance with the patient, effectively using evidence-based motivational strategies, acknowledging the patient's individual barriers, making reminder phone calls, and creating a positive environment.¹⁰⁵ Further, providers who can recommend and/or provide a broad range of RSS, such as child care, housing, and transportation, can improve retention in treatment.¹⁰⁶

Engaging, effective treatment also involves culturally competent care. For example, treatment programs that provide gender-specific and gender-responsive care are more likely to enhance women's treatment outcomes.¹⁰⁷ Tailoring treatment to involve family and community is particularly effective for certain groups. For example, American Indians or Alaska Natives may require specific elements in their treatment plan that respond to their unique cultural experiences and to intergenerational and historical trauma and trauma from violent encounters.¹⁰⁸ Language and literacy (including health literacy) may also affect how a person responds to the treatment environment.^109-112 Race and ethnicity, sexual orientation, gender identity, and economic status can play significant roles in treatment initiation, engagement, and completion.^107,113,114

Substance use disorder treatment programs also have an obligation to prepare for disasters within their communities that can affect the availability of services. A disaster can disrupt a program's ability to provide treatment services or an individual's ability to maintain treatment. Individuals in recovery, for example, may relapse due to sudden discontinuation of services or stress when having to cope with effects of a disaster. Individuals receiving MAT could be at risk of serious withdrawal symptoms if medications are stopped abruptly. Others may face challenges without their treatment program's support.¹¹⁵ Therefore, planning for disasters and other large scale emergencies is critical to prevent or reduce the impact of interruptions in treatment services.

Treatment Setting and the Continuum of Care

As indicated above, the treatment of addiction is delivered in predominantly freestanding programs that differ in their setting (hospital, residential, or outpatient); in the frequency of care delivery (daily sessions to monthly visits); in the range of treatment components offered; and in the planned duration of care. In general, as patients progress in treatment and begin to meet the goals of their individualized treatment plan, they transfer from clinical management in residential or intensive outpatient programs to less clinically intensive outpatient programs that promote patient self-management.

A typical progression for someone who has a severe substance use disorder might start with 3 to 7 days in a medically managed withdrawal program, followed by a 1- to 3-month period of intensive rehabilitative care in a residential treatment program, followed by continuing care, first in an intensive outpatient program (2 to 5 days per week for a few months) and later in a traditional outpatient program that meets 1 to 2 times per month. For many patients whose current living situations are not conducive to recovery, outpatient services should be provided in conjunction with recovery-supportive housing.

FOR MORE ON THIS TOPIC

See Chapter 5 - Recovery: The Many Paths to Wellness.

In general, patients with serious substance use disorders are recommended to stay engaged for at least 1 year in the treatment process, which may involve participation in three to four different programs or services at reduced levels of intensity, all of which are ideally designed to help the patient prepare for continued self-management after treatment ends.^56,116 This expected trajectory of care explains why efforts to maintain patient motivation and engagement are important. Brief summaries of the major levels of the treatment continuum are discussed below.

Medically monitored and managed inpatient care is an intensive service delivered in an acute, inpatient hospital setting.¹⁸ These programs are typically necessary for individuals who require withdrawal management, primary medical and nursing care, and for those with co-occurring mental and physical health conditions.¹⁸ Treatment is usually provided by an interdisciplinary team of health care professionals, available 24 hours a day, who can address serious mental and physical health needs.^18,91

FOR MORE ON THIS TOPIC

See the section on “Acute Stabilization and Withdrawal Management” earlier in this chapter.

Residential services offer organized services, also in a 24-hour setting but outside of a hospital. These programs typically provide support, structure, and an array of evidence-based clinical services.¹⁸ Such programs are appropriate for physically and emotionally stabilized individuals who may not have a living situation that supports recovery, may have a history of relapse, or have co-occurring physical and/or mental illnesses.

Partial hospitalization and intensive outpatient services range from counseling and education to clinically intensive programming.¹⁸ Partial hospitalization programs are used as a step-down treatment option after completing residential treatment and are usually available 6 to 8 hours a day during the work week.¹⁸ These services are considered to be approximately as intensive but less restrictive than residential programs⁹¹ and are appropriate for patients living in an environment that supports recovery but who need structure to avoid relapse.

Outpatient services provide both group and individual behavioral interventions and medications when appropriate.⁹¹ These components of care can be offered during the day, before or after work or school, or in the evenings and weekends. Typically, outpatient programs are appropriate as the initial level of care for individuals with a mild to moderate substance use disorder or as continuing care after completing more intensive treatment.¹⁸ Outpatient programs are also suitable for individuals with co-occurring mental health conditions.

Evidence-based Treatment: Components of Care

Regardless of the substance for which the individual seeks treatment or the setting or level of care, all substance use disorder treatment programs are expected to offer an individualized set of evidence-based clinical components. These components are clinical practices that research has shown to be effective in reducing substance use and improving health and functioning. These include behavioral therapies, medications, and RSS. Treatment programs that offer more of these evidence-based components have the greatest likelihood of producing better outcomes.

Medications and Medication-Assisted Treatment

Five medications, approved by the FDA, have been developed to treat alcohol and opioid use disorders. Currently, no approved medications are available to treat marijuana, amphetamine, or cocaine use disorders.¹¹⁷ Table 4.4 lists these medications and they are discussed individually in the text that follows.

Table 4.4

Pharmacotherapies Used to Treat Alcohol and Opioid Use Disorders.

Like all other FDA-approved medications, those listed in Table 4.4 demonstrate “well-supported” experimental evidence of safety and effectiveness¹²⁰ for improving outcomes for individuals with alcohol and opioid use disorders.¹¹⁷ At the same time, all of these medications have side effects; two (methadone and buprenorphine) have the potential to be misused, and methadone (and to a lesser extent buprenorphine) has the potential for overdose. For these reasons, only appropriately trained health care professionals should decide whether medication is needed as part of treatment, how the medication is provided in the context of other clinical services, and under what conditions the medication should be withdrawn or terminated.

The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT.¹²¹ MAT is a highly effective treatment option for individuals with alcohol and opioid use disorders. Studies have repeatedly demonstrated the efficacy of MAT at reducing illicit drug use and overdose deaths,^122,123 improving retention in treatment,¹²⁴ and reducing HIV transmission.¹²²

Some medications used to treat opioid use disorders can be used to manage withdrawal and as maintenance treatment to reduce craving, lessen withdrawal symptoms, and maintain recovery.⁵⁶ These medications are used to help a patient function comfortably without illicit opioids or alcohol while balance is gradually restored to the brain circuits that have been altered by prolonged substance use.

FOR MORE ON THIS TOPIC

See Chapter 2 - The Neurobiology of Substance Use, Misuse, and Addiction.

Prescribed in this fashion, medications for substance use disorders are in some ways like insulin for patients with diabetes. Insulin reduces symptoms by normalizing glucose metabolism, but it is part of a broader disease control strategy that also employs diet change, education on healthy living, and self-monitoring. Whether treating diabetes or a substance use disorder, medications are best employed as part of a broader treatment plan involving behavioral health therapies and RSS, as well as regular monitoring.

State agencies that oversee substance use disorder treatment programs use a variety of strategies to promote implementation of MAT, including education and training, financial incentives (e.g., linking funding to the provision of MAT), policy mandates, and support for infrastructure development.⁵ Nevertheless, multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing medications; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation.⁵

Medication-Assisted Treatment for Opioid Use Disorders

MAT for patients with a chronic opioid use disorder must be delivered for an adequate duration in order to be effective. Patients who receive MAT for fewer than 90 days have not shown improved outcomes.¹²⁵ One study suggested that individuals who receive MAT for fewer than 3 years are more likely to relapse than those who are in treatment for 3 or more years.¹²⁶ Three medications are commonly used to treat opioid use disorders: methadone, buprenorphine, and naltrexone.

Methadone is a synthetic opioid agonist that has been used to treat the symptoms of withdrawal from heroin and other opioids.¹²⁷ More than 40 years of research support the use of methadone as an effective treatment for opioid use disorder.^121,128,129 It is also used in the treatment of patients with chronic, severe pain¹³⁰ as a therapeutic alternative to morphine sulfate and other opioid analgesics.¹³¹ Any licensed physician can prescribe methadone for the treatment of pain, but methadone may only be dispensed for treatment of an opioid use disorder within licensed methadone treatment programs.

KEY TERMS

Agonist. A chemical substance that binds to and activates certain receptors on cells, causing a biological response. Fentanyl and methadone are examples of opioid receptor agonists.

Long-term methadone maintenance treatment for opioid use disorders has been shown to be more effective than short-term withdrawal management,¹³² and it has demonstrated improved outcomes for individuals (including pregnant women and their infants) with opioid use disorders.¹³³ Studies have also indicated that methadone reduces deaths, HIV risk behaviors, and criminal behavior associated with opioid drug seeking.^134,135

The use of methadone to treat opioid use disorders has much in common with treatments for other substance use disorders and other chronic illnesses. However, it has one significant structural and cultural difference. Under regulations dating back to the early 1970s, the federal government created special methadone programs for adults with opioid use disorders. Originally referred to as “methadone treatment programs,” these treatment facilities were created to provide special management of the medical and legal issues associated with the use of this potent, long-acting opioid.

The use of opioid agonist medications to treat opioid use disorders has always had its critics. Many people, including some policymakers, authorities in the criminal justice system, and treatment providers, have viewed maintenance treatments as “substituting one substance for another”⁸⁵ and have adhered instead to an abstinence-only philosophy that avoids the use of medications, especially those that activate opioid receptors. Such views are not scientifically supported; the research clearly demonstrates that MAT leads to better treatment outcomes compared to behavioral treatments alone. Moreover, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death. Decades of research have shown that the benefits of MAT greatly outweigh the risks associated with diversion.

KEY TERMS

Drug diversion. A medical and legal concept involving the transfer of any legally prescribed controlled substance from the person for whom it was prescribed to another person for any illicit use.

Today, methadone treatment programs, now called Opioid Treatment Programs (OTPs), must be certified by SAMHSA and registered by the U.S. Drug Enforcement Administration (DEA). OTPs are predominantly outpatient programs (approximately 95 percent) that provide pharmacotherapy in combination with behavioral therapies and other RSS.¹³⁶ OTPs incorporate principles of harm reduction and benefit both program participants and the community¹³⁷ by reducing opioid use, mortality, crime associated with opioid use disorders, and infectious disease transmission. Buprenorphine and naltrexone may also be provided in OTPs.⁶¹

Individuals receiving medication for opioid use disorders in an OTP must initially take their doses daily under observation.^138,139 After a period of orientation, patients are typically started at a dose of 20 to 30 mg and gradually increased to 80 mg or more per day, until craving and opioid misuse are significantly reduced. During this period, all dosing occurs at the OTP, but following stabilization and initially positive results, the stabilized patient may be given a “take-home” supply of his or her dose to self-administer per the federal opioid treatment standard regulations 42 CFR 8.12(i).

Buprenorphine is available as a sublingual tablet and a sublingual or buccal film. In addition, in May 2016, an implantable formulation of buprenorphine was approved by the FDA. For individuals who are already on a stable low to moderate dose of buprenorphine, the implant delivers a constant low dose of buprenorphine for 6 months. Buprenorphine is associated with improved outcomes compared to placebo for individuals (including pregnant women and their infants) with opioid use disorders,¹⁴⁰ and it is effective in reducing illegal opioid use.¹²⁹

Buprenorphine is a partial opioid agonist, meaning that it binds to and activates opioid receptors but with less intensity than full agonists. As a result, there is an upper limit to how much euphoria, pain relief, or respiratory depression buprenorphine can produce.^56,141 However, buprenorphine still may result in overdose if used with tranquilizers and/or alcohol, and some diversion has been reported, although studies suggest most diverted buprenorphine is used therapeutically (e.g., to control cravings), not to get high.^142-144

Clinical experience and research protocols indicate that buprenorphine initiation and stabilization during the induction period is an important part of successful treatment for individuals with opioid use disorder.¹⁴⁵ Buprenorphine can be prescribed alone or as a combination medication that includes naloxone, an opioid antagonist medication.¹⁴⁵ If this combined medication is taken as prescribed, the naloxone has no appreciable effects. However, if the combined medication is injected, the naloxone component can precipitate an opioid withdrawal syndrome, and in this way serves as a deterrent to misuse by injection.¹⁴⁵

Buprenorphine may be prescribed by physicians who have met the statutory requirements for a waiver in accordance with the Controlled Substances Act (21 U.S.C. 823(g)(2)(D)(iii)).¹⁴⁶ However, physicians using the waiver are limited in the number of patients they can treat with this medication. This patient limit does not apply to OTPs that dispense buprenorphine on site because the OTP operating in this capacity is doing so under 21 U.S.C. 823(g)(1) and 42 CFR Part 8, and not under 21 U.S.C. 823(g)(2)(B).

When they first receive their waiver, physicians can provide buprenorphine treatment for only up to 30 individuals. After the first year they can request to treat up to 100.¹⁴⁷ However, lack of physician availability to prescribe buprenorphine has been a significant limitation on access to this effective medication. Although approximately 435,000 primary care physicians practice medicine in the United States,¹⁴⁸ only slightly more than 30,000 have a buprenorphine waiver,¹⁴⁹ and only about half of those are actually treating opioid use disorders.¹⁵⁰ To address this limitation and narrow the treatment gap, a final rule was published on July 8, 2016, expanding access to MAT by allowing eligible practitioners to request approval to treat up to 275 patients.¹⁴⁷

Additionally, on July 22, 2016, the Comprehensive Addiction and Recovery Act (CARA) was signed into law. CARA temporarily expands eligibility to prescribe buprenorphine-based drugs for MAT for substance use disorders to qualifying nurse practitioners and physician assistants through October 1, 2021.

FOR MORE ON THIS TOPIC

See the section on “Comprehensive Addiction and Recovery Act (CARA)” in Chapter 6 - Health Care Systems and Substance Use Disorders.

Naltrexone is an opioid antagonist that binds to opioid receptors and blocks their activation; it produces no opioid-like effects and is not abusable. It prevents other opioids from binding to opioid receptors so that they have little to no effect. It also interrupts the effects of any opioids in a person's system, precipitating an opioid withdrawal syndrome in opioid-dependent patients, so it can be administered only after a complete detoxification from opioids. There is also no withdrawal from naltrexone when the patient stops taking it. Naltrexone may be appropriate for people who have been successfully treated with buprenorphine or methadone who wish to discontinue use but still be protected from relapse; people who prefer not to take an opioid agonist; people who have completed detoxifications and/or rehabilitation or are being released from incarceration and expect to return to an environment where drugs may be used and wish to avoid relapse; and adolescents or young adults with opioid dependence.¹⁵¹

Because naltrexone is not a controlled substance, it can be prescribed or administered by any physician, nurse practitioner, or physician assistant with prescribing authority. Naltrexone comes in two formulations: oral and extended-release injectable. Oral naltrexone can be effective for those individuals who are highly motivated and/or supported with observed daily dosing. Extended-release injectable naltrexone, which is administered on a monthly basis, addresses the poor compliance associated with oral naltrexone since it provides extended protection from relapse and reduces cravings for 30 days.^152,153

Medication-Assisted Treatment for Alcohol Use Disorders

A number of factors should be weighed in determining the need for medication when treating an individual for an alcohol use disorder, such as the patient's motivation for treatment, potential for relapse, and severity of co-existing conditions.¹²⁰ Three FDA-approved medications are currently available to treat alcohol use disorder: disulfiram, naltrexone, and acamprosate.¹¹⁷ None of these medications carries a risk of misuse or addiction, and thus none is a DEA-scheduled substance. Each has a distinct effectiveness and side effect profile. Prescribing health care professionals should be familiar with these side effects and take them into consideration before prescribing.¹⁵⁴ Providers can obtain additional information from materials produced by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and SAMHSA.^155,156

Research studies on the efficacy of medications to treat alcohol use disorders have demonstrated that most patients show benefit, although individual response can be difficult to predict.^154,157 MAT interventions for alcohol use disorders can be provided in both non-specialty and specialty care settings and are most beneficial when combined with behavioral interventions and brief support.¹⁵⁴

Disulfiram is a medication that inhibits normal breakdown of acetaldehyde which is produced by the metabolism of alcohol, thus rapidly increasing acetaldehyde in the blood which produces an aversive response. Thus, once disulfiram is taken by mouth, any alcohol consumed results in rapid buildup of acetaldehyde and a negative reaction or sickness results. The intensity of this reaction is dependent on the dose of disulfiram and the amount of alcohol consumed.¹⁵⁸ Effects from a disulfiram-alcohol reaction include warmth and flushing of the skin, increased heart rate, palpitations, a drop in blood pressure, nausea and/or vomiting, sweating, dizziness, and headache.¹⁵⁹ In this way, disulfiram essentially punishes alcohol consumption and indirectly rewards abstinence.¹¹⁷

Disulfiram was the first medication approved by the FDA to treat alcohol use disorder and its efficacy has been widely studied.¹⁶⁰ Most studies have demonstrated that disulfiram, when given under supervision, is more effective than placebo in treating alcohol use disorders.¹⁵⁴ A major limitation of disulfiram is adherence, which is typically poor, thereby reducing the medication's effectiveness. Disulfiram is most effective when its use is supervised or observed, which has been found to increase compliance.^154,159 Negotiating with the patient to have a spouse or significant other provide supervision offers both the incentive to take the medication and the documentation that the medication is being taken.¹⁶¹ The best candidates for disulfiram are patients with motivation for treatment and a desire to be abstinent. Thus, an individual who wants to reduce, but not stop, drinking is not a candidate for disulfiram. Disulfiram should also be avoided in individuals with advanced liver disease.¹⁶²

Naltrexone is the opioid antagonist described above that is used to treat opioid use disorder. Because it blocks some opioid receptors, naltrexone counteracts some of the pleasurable aspects of drinking.^154,159 Unlike disulfiram, naltrexone does not interact with alcohol to produce a severe reaction.¹⁶³ As noted before, naltrexone comes in two formulations: oral and extended-release injectable.

Many studies have examined the effectiveness of naltrexone in treating alcohol use disorders.¹⁵⁴ Several research reviews have found that it reduces the risk of heavy drinking in patients who are abstinent for at least several days at the time treatment begins.^154,160 However, as with disulfiram, medication compliance can be a problem with the oral formulation. Adherence to taking the medication increases under conditions where it is administered and observed by a trusted family member or when the extended-release injectable, which requires only a single monthly injection, is used.¹⁶⁴ Naltrexone should not be prescribed to patients with acute hepatitis, renal failure, or liver failure.¹⁶²

Acamprosate is a medication that normalizes the alcohol-related neurochemical changes in the brain glutamate systems and thereby reduces the symptoms of craving that can prompt a relapse to pathological drinking.¹¹⁷ Acamprosate has been found to be an effective medication when used concurrently with behavioral interventions and, as with other medications for alcohol use disorders, works best in motivated patients.^117,165 Reviews show that acamprosate is effective in reducing relapse¹⁶⁶ and effective when used to maintain abstinence from alcohol.¹⁶⁷

Emerging Treatment Technologies

Technological advancements are changing not only the face of health care generally, but also the treatment of substance use disorders. In this regard, approximately 20 percent of substance use disorder treatment programs have adopted electronic health record (EHR) systems. With the growing adoption of EHRs, individuals and their providers can more easily access and share treatment records to improve coordination of care.²¹⁶ In turn, information sharing through EHRs can lead to improved quality and efficiency of service delivery, reduced treatment gaps, and increased cost savings to health systems.

The use of telehealth to deliver health care, provide health information or education, and monitor the effects of care, has also rapidly increased.²¹⁷ Telehealth can be facilitated through a variety of media, including smartphones, the Internet, videoconferencing, wireless communication, and streaming media. It offers alternative, cost-effective care options for individuals living in rural or remote areas or when physically travelling to a health care facility poses significant challenges.

Technology-based interventions offer many potential advantages. They can increase access to care in underserved areas and settings; free up time so that service providers can care for more clients; provide alternative care options for individuals hesitant to seek in-person treatment; increase the chances that interventions will be delivered as they were designed and intended to be delivered; and decrease costs.^218-222 Further, studies show that most individuals already have access to the necessary tools to engage in technology-based care; about 92 percent of United States adults own a cell phone²²³ and 85 percent use the Internet.²²⁴

Research on the effectiveness of technology-assisted care within substance use disorder treatment focuses on three main applications: (1) technology as an add-on to enhance standard care; (2) technology as a substitute for a portion of standard care; and (3) technology as a replacement for standard care.²²¹ The current evidence base of technology-based interventions for substance use disorder treatment is limited, though it is growing.^221,225-227 For this reason, these technologies can only be considered “promising” at this time. Table 4.5 shows the state of evidence supporting innovative technology-assisted interventions, several of which are discussed in the Electronic Treatment Interventions and Electronic Clinical and Recovery Support Tools sections.

Table 4.5

Examples of Technology-Assisted Interventions.

Considerations for Specific Populations

Recommendations for Research

Although the field of treatment for substance use disorders has made substantial progress, additional types of research are needed. Research involving early interventions and various components of treatment must move from rigorously controlled trials to natural delivery settings and a broader mix of patient types. Because rigorously controlled trials must focus on specific diagnoses and carefully characterized patient types, it is often the case that the samples used in these trials are not representative of the real-world populations who need treatment. For example, many opioid medication trials involve “opioid-only” populations, whereas in practice most patients with opioid use disorders also have alcohol, marijuana, and/or cocaine use disorders. Rigorously controlled trials are necessary to establish efficacy, but interventions that seem to be effective in these studies too often cannot be implemented in real-world settings because of a lack of workforce training, inadequate insurance coverage, and an inability to adequately engage the intended patient population.

As has been documented in several chapters within this Report, the great majority of patients with substance use disorders do not receive any form of treatment. Nonetheless, many of these individuals do access primary or general medical care in community clinics or school settings and research is needed to determine the availability and efficacy of treatment in these settings and to identify ways in which access to treatment in these settings could be improved. The current failure to acknowledge and address substance use disorders in these settings has reduced the quality and increased the costs of health care. Moreover, access and referral to specialty substance use disorder care from primary care settings is neither easy nor quick. Better integration between primary care and specialty care and additional treatment options within primary care are needed. Primary care physicians need to be better prepared to identify, assist, and refer patients, when appropriate. If treatment is delivered in primary care, it should be practical for delivery within these settings and attractive, engaging, accessible and affordable for affected patients.

Buprenorphine or naloxone treatment for opioid misuse should also be available in emergency departments.²⁹⁷ Here, the goals of treatment would be the reduction of substance use combined with better engagement in and adherence to treatment for any associated medical illness. Therefore, treatment research outside of traditional substance use disorder treatment programs is needed.

As of June 2016, four states, plus the District of Columbia, have legalized recreational marijuana, and many more have permitted medical marijuana use. The impact of the changes on levels of marijuana and other drug and alcohol use, simultaneous use, and related problems such as motor vehicle crashes and deaths, overdoses, hospitalizations, and poor school and work performance, must be evaluated closely. Accurate and practical marijuana screening and early intervention procedures for use in general and primary care settings are needed. Not only must it be determined which assessment tools are appropriate for the various populations that use marijuana, but also which treatments are generalizable from research to practice, especially in primary care and general mental health care settings.

Current research suggests that it is useful to educate and train first responders, peers, and family members of those who use opioids to use naloxone to prevent and reverse potential overdose-related deaths. However, more research is needed to identify strategies to encourage the subsequent engagement of those who have recovered from overdose into appropriate treatment. In this work, it will be important to consider contextual factors such as age, gender identity, race and ethnicity, sexual orientation, economic status, community resources, faith beliefs, co-occurring mental or physical illness, and many other personal issues that can work against the appropriateness and ultimately the usefulness of a treatment strategy.

Opioid agonist therapies are effective in stabilizing the lives of individuals with severe opioid use disorders. However, many important clinical and social questions remain about whether, when, and how to discontinue medications and related services. This is an important question for many other areas of medicine where maintenance medications are continued without significant change and often without attention to other areas of clinical progress.

At the same time, it is clear from many studies over the decades that detoxification following an arbitrary maintenance time period (e.g., 90 days, 180 days), or performed without continuing supports, is rarely effective in disengaging patients from opioid use disorders and may lead to relapse and overdose. Thus, more research is needed to explore if, when, and how patients can be transitioned from MAT to non-medication status within the context of “personalized medicine,” to provide both patients and clinical staff appropriate therapeutic guidance.

Regarding personalized medicine, research is needed on how to implement multidisciplinary, collaborative, and patient-centered care for persons with opioid use disorders and chronic pain, in a manner effectively treating both diseases together with any psychiatric comorbidities that may undermine recovery. Precision medicine research is also needed on how to individually tailor such interventions to optimize care management for patient groups in which there is overlap between pain-related psychological distress and stress-related opioid misuse.²⁹⁸

References

1.

HealthIT​.gov. What is telehealth? How is telehealth different from telemedicine? 2014. [June 17, 2016]. Retrieved from https://www​.healthit​.gov/providers-professionals​/faqs/what-telehealth-how-telehealth-different-telemedicine.

2.

Medina J. Symptoms of substance use disorders (Revised for DSM-5). 2015. [March 9, 2016]. Retrieved from http://psychcentral​.com​/disorders/revised-alcoholsubstance-use-disorder/

3.

Substance Abuse and Mental Health Services Administration. Behavioral health treatments and services. 2015. [January 25, 2016]. Retrieved from http://www​.samhsa.gov/treatment.

4.

Evashwick C. Creating the continuum of care. Health Matrix. 1988;7(1):30–39. [PubMed: 10293297]

5.

Rieckmann T, Kovas AE, Rutkowski BA. Adoption of medications in substance abuse treatment: Priorities and strategies of single state authorities. Journal of Psychoactive Drugs. 2010;42(Suppl 6):227–238. [PMC free article: PMC3640346] [PubMed: 21138199]

6.

Udo T, Vasquez E, Shaw BA. A lifetime history of alcohol use disorder increases risk for chronic medical conditions after stable remission. Drug and Alcohol Dependence. 2015;157:68–74. [PubMed: 26482092]

7.

Kline-Simon AH, Weisner C, Sterling S. Point prevalence of co-occurring behavioral health conditions and associated chronic disease burden among adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 2016;55(5):408–414. [PubMed: 27126855]

8.

Puddy RW, Wilkins N. Understanding evidence Part 1: Best available research evidence A guide to the continuum of evidence of effectiveness. Atlanta, GA: Centers for Disease Control and Prevention; 2011.

9.

Compton WM, Thomas YF, Stinson FS, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry. 2007;64(5):566–576. [PubMed: 17485608]

10.

Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry. 2007;64(7):830–842. [PubMed: 17606817]

11.

Ettner SL, Huang D, Evans E, Ash DR, Hardy M, Jourabchi M, Hser YI. Benefit-cost in the California treatment outcome project: Does substance abuse treatment “pay for itself”? Health Services Research. 2006;41(1):192–213. [PMC free article: PMC1681530] [PubMed: 16430607]

12.

McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695. [PubMed: 11015800]

13.

Pasareanu AR, Opsal A, Vederhus J, Kristensen Ø, Clausen T. Quality of life improved following in-patient substance use disorder treatment. Health and Quality of Life Outcomes. 2015;13(35) [PMC free article: PMC4364507] [PubMed: 25889576]

14.

Garner BR, Scott CK, Dennis ML, Funk RR. The relationship between recovery and health-related quality of life. Journal of Substance Abuse Treatment. 2014;47(4):293–298. [PMC free article: PMC4138291] [PubMed: 25012552]

15.

Tracy EM, Laudet AB, Min MO, Kim H, Brown S, Jun MK, Singer L. Prospective patterns and correlates of quality of life among women in substance abuse treatment. Drug and Alcohol Dependence. 2012;124(3):242–249. [PMC free article: PMC3366154] [PubMed: 22333265]

16.

Sobell MB, Sobell LC. Guided self-change model of treatment for substance use disorders. Journal of Cognitive Psychotherapy. 2005;19(3):199–210.

17.

Center for Substance Abuse Treatment. Brief interventions and brief therapies for substance abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration; 1999. (Treatment improvement protocol (TIP) series, No. 34). (HHS Publication No (SMA) 12-3952)

18.

American Society of Addiction Medicine. ASAM patient placement criteria for the treatment of substance-related disorders. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 2001.

19.

Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016.

20.

Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: A brief review. Journal of Psychoactive Drugs. 2012;44(4):307–317. [PMC free article: PMC3801194] [PubMed: 23210379]

21.

Manuel JK, Satre DD, Tsoh J, Moreno-John G, Ramos JS, McCance-Katz EF, Satterfield JM. Adapting screening, brief intervention, and referral to treatment for alcohol and drugs to culturally diverse clinical populations. Journal of Addiction Medicine. 2015;9(5):343–351. [PMC free article: PMC4626638] [PubMed: 26428359]

22.

Harris SK, Knight JR. Putting the screen in screening: Technology-based alcohol screening and brief interventions in medical settings. Alcohol Research: Current Reviews. 2014;36(1):63–79. [PMC free article: PMC4432859] [PubMed: 26259001]

23.

Benningfield MM, Riggs P, Stephan SH. The role of schools in substance use prevention and intervention. Child and Adolescent Psychiatric Clinics of North America. 2015;24(2):291–303. [PubMed: 25773325]

24.

O'Donnell A, Anderson P, Newbury-Birch D, Schulte B, Schmidt C, Reimer J, Kaner E. The impact of brief alcohol interventions in primary healthcare: A systematic review of reviews. Alcohol and Alcoholism. 2014;49(1):66–78. [PMC free article: PMC3865817] [PubMed: 24232177]

25.

Schmidt CS, Schulte B, Seo HN, Kuhn S, A OD, Kriston L, Reimer J. Meta-analysis on the effectiveness of alcohol screening with brief interventions for patients in emergency care settings. Addiction. 2016;111(5):783–794. [PubMed: 26637990]

26.

Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence. 2009;99(1):280–295. [PMC free article: PMC2760304] [PubMed: 18929451]

27.

Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence. 2005;77(1):49–59. [PubMed: 15607841]

28.

Fuster D, Cheng DM, Wang N, Bernstein JA, Palfai TP, Alford DP, Saitz R. Brief intervention for daily marijuana users identified by screening in primary care: A subgroup analysis of the ASPIRE randomized clinical trial. Substance Abuse. 2015:1–7. [PMC free article: PMC4826635] [PubMed: 26453188]

29.

Saitz R. Screening and brief intervention for unhealthy drug use: Little or no efficacy. Frontiers in Psychiatry. 2014;5(121) [PMC free article: PMC4151000] [PubMed: 25228887]

30.

Estee S, He L, Mancuso D, Felver B. Medicaid cost outcomes. Olympia, WA: Department of Social and Health Services, Research and Data Analysis Division; 2006.

31.

Levy SJ, Williams JF., Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1) [PubMed: 27325634]

32.

Levy SJ, Kokotailo PK. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011;128(5):e1330–e1340. [PubMed: 22042818]

33.

Coble YD, Estes EH, Head CA, Karlan MS, Kennedy WR, Numann PJ, Strong JP. Confidential health services for adolescents. JAMA. 1993;269(11):1420–1424.

34.

Canfield SE, Dahm P. Rating the quality of evidence and the strength of recommendations using GRADE. World Journal of Urology. 2011;29(3):311–317. [PubMed: 21387101]

35.

Committee on Health Care for Underserved Women. At-risk drinking and alcohol dependence: Obstetric and gynecologic implications. Obstetrics & Gynecology. 2011;118(2 Pt 1):383–388. [PubMed: 21775870]

36.

Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. American Family Physician. 2013;88(2):113–121. [PubMed: 23939642]

37.

Center for Substance Abuse Treatment. Brief interventions and brief therapies for substance abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration; 1999. Chapter 2—Brief interventions in substance abuse treatment. (Treatment improvement protocol (TIP) series, No. 34). (HHS Publication No (SMA) 12-3952)

38.

McNeely J, Cleland CM, Strauss SM, Palamar JJ, Rotrosen J, Saitz R. Validation of self-administered single-item screening questions (SISQs) for unhealthy alcohol and drug use in primary care patients. Journal of General Internal Medicine. 2015;30(12):1757–1764. [PMC free article: PMC4636560] [PubMed: 25986138]

39.

McNeely J, Strauss SM, Saitz R, Cleland CM, Palamar JJ, Rotrosen J, Gourevitch MN. A brief patient self-administered substance use screening tool for primary care: Two-site validation study of the Substance Use Brief Screen (SUBS). The American Journal of Medicine. 2015;128(7):784.e789–784.e719. [PMC free article: PMC4475501] [PubMed: 25770031]

40.

Clark DB, Martin CS, Chung T, Gordon AJ, Fiorentino L, Tootell M, Rubio DM. Screening for underage drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition alcohol use disorder in rural primary care practice. The Journal of Pediatrics. 2016;173:214–220. [PMC free article: PMC4884494] [PubMed: 27059911]

41.

Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test. Journal of General Internal Medicine. 2009;24(7):783–788. [PMC free article: PMC2695521] [PubMed: 19247718]

42.

Levy S, Dedeoglu F, Gafin JM, Garvey KC, Harstad E, MacGinnitie A, Wisk LE. A screening tool for assessing alcohol use risk among medically vulnerable youth. PLoS One. 2016;11(5) [PMC free article: PMC4882018] [PubMed: 27227975]

43.

National Institute on Drug Abuse. Chart of evidence-based screening tools for adults and adolescents. 2015. [March 9, 2016]. Retrieved from https://www​.drugabuse​.gov/nidamed-medical-health-professionals​/tool-resources-your-practice​/screening-assessment-drug-testing-resources​/chart-evidence-based-screening-tools-adults.

44.

Miller WR, Rollnick S. Motivational interviewing: Helping people change. 3rd ed. New York, NY: Guilford Press; 2012.

45.

Lundahl B, Moleni T, Burke BL, Butters R, Tollefson D, Butler C, Rollnick S. Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling. 2013;93(2):157–168. [PubMed: 24001658]

46.

Center for Substance Abuse Treatment. Enhancing motivation for change in substance abuse treatment. Rockville, MD: Substance Abuse and Mental Health Services Administration; 1999. Chapter 3—Motivational interviewing as a counseling style. (Treatment improvement protocol (TIP) series, No. 35). (HHS Publication No (SMA) 13-4212)

47.

National Quality Forum. Evidence-based treatment practices for substance use disorders: Workshop proceedings. NQFWP-06-05. Washington, DC: National Quality Forum; 2005.

48.

Roy-Byrne P, Bumgardner K, Krupski A, Dunn C, Ries R, Donovan D, Graves MC. Brief intervention for problem drug use in safety-net primary care settings: A randomized clinical trial. JAMA. 2014;312(5):492–501. [PMC free article: PMC4599980] [PubMed: 25096689]

49.

Saitz R, Palfai TP, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, Samet JH. Screening and brief intervention for drug use in primary care: The ASPIRE randomized clinical trial. JAMA. 2014;312(5):502–513. [PMC free article: PMC4667772] [PubMed: 25096690]

50.

Gelberg L, Andersen RM, Afifi AA, Leake BD, Arangua L, Vahidi M, Fleming MF. Project QUIT (Quit Using Drugs Intervention Trial): A randomized controlled trial of a primary care-based multi-component brief intervention to reduce risky drug use. Addiction. 2015;110(11):1777–1790. [PMC free article: PMC4948983] [PubMed: 26471159]

51.

Yuma-Guerrero PJ, Lawson KA, Velasquez MM, von Sternberg K, Maxson T, Garcia N. Screening, brief intervention, and referral for alcohol use in adolescents: A systematic review. Pediatrics. 2012;130(1):115–122. [PubMed: 22665407]

52.

Mitchell SG, Gryczynski J, O'Grady KE, Schwartz RP. SBIRT for adolescent drug and alcohol use: Current status and future directions. Journal of Substance Abuse Treatment. 2013;44(5):463–472. [PMC free article: PMC3602212] [PubMed: 23352110]

53.

Sterling S, Kline-Simon AH, Satre DD, Jones A, Mertens J, Wong A, Weisner C. Implementation of screening, brief intervention, and referral to treatment for adolescents in pediatric primary care: A cluster randomized trial. JAMA Pediatrics. 2015;169(11) [PMC free article: PMC4779618] [PubMed: 26523821]

54.

Ozechowski TJ, Becker SJ, Hogue A. SBIRT-A: Adapting SBIRT to maximize developmental fit for adolescents in primary care. Journal of Substance Abuse Treatment. 2016;62:28–37. [PMC free article: PMC4824303] [PubMed: 26742723]

55.

Satre DD, Campbell CI, Gordon NP, Weisner C. Ethnic disparities in accessing treatment for depression and substance use disorders in an integrated health plan. The International Journal of Psychiatry in Medicine. 2010;40(1):57–76. [PMC free article: PMC2922921] [PubMed: 20565045]

56.

Center for Health Information and Analysis. Access to substance use disorder treatment in Massachusetts. Boston, MA: Center for Health Information and Analysis, Commonwealth of Massachusetts; 2015. (15-112-CHIA-01)

57.

DeFlavio JR, Rolin SA, Nordstrom BR, Kazal LA Jr. Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural Remote Health. 2015;15(3019):1–11. [PubMed: 25651434]

58.

Quest TL, Merrill JO, Roll J, Saxon AJ, Rosenblatt RA. Buprenorphine therapy for opioid addiction in rural Washington: The experience of the early adopters. Journal of Opioid Management. 2012;8(1):29–38. [PMC free article: PMC4367201] [PubMed: 22479882]

59.

Hawk KF, Vaca FE, D'Onofrio G. Reducing fatal opioid overdose: Prevention, treatment and harm reduction strategies. The Yale Journal of Biology and Medicine. 2015;88(3):235–245. [PMC free article: PMC4553643] [PubMed: 26339206]

60.

Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug and Alcohol Review. 2006;25(6):611–624. [PubMed: 17132577]

61.

Hunt N, Ashton M, Lenton S, Mitcheson L, Nelles B, Stimson G. A review of the evidence-base for harm reduction approaches to drug use. 2003. [June 20, 2016]. Retrieved from http://www​.forward-thinking-on-drugs​.org/review2-print.html.

62.

Wheeler E, Davidson PJ, Jones TS, Irwin KS. Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR. 2012;61(6):101–105. [PMC free article: PMC4378715] [PubMed: 22337174]

63.

Marlatt GA, Larimer ME, Witkiewitz K. Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York, NY: Guilford Press; 2011.

64.

Gottheil E, Sterling RC, Weinstein SP. Outreach engagement efforts: Are they worth the effort? The American Journal of Drug and Alcohol Abuse. 1997;23(1):61–66. [PubMed: 9048147]

65.

Center for Substance Abuse Treatment. Substance abuse treatment: Addressing the specific needs of women. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2009. (Treatment improvement protocol (TIP) series, No. 51). (HHS Publication No (SMA) 15-4426)

66.

Reback CJ, Fletcher JB. HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach. AIDS and Behavior. 2014;18(7):1359–1367. [PMC free article: PMC4209944] [PubMed: 24287786]

67.

Carmona J, Slesnick N, Guo X, Murnan A, Brakenhoff B. Predictors of outreach meetings among substance using homeless youth. Community Mental Health Journal. 2015:1–10. [PubMed: 26293750]

68.

Tobias C, Cunningham WE, Cunningham CO, Pounds MB. Making the connection: The importance of engagement and retention in HIV medical care. AIDS Patient Care and STDs. 2007;21(S1):S-3–S-8. [PubMed: 17563287]

69.

Fisk D, Rakfeldt J, McCormack E. Assertive outreach: An effective strategy for engaging homeless persons with substance use disorders into treatment. The American Journal of Drug and Alcohol Abuse. 2006;32(3):479–486. [PubMed: 16864475]

70.

Bowman S, Engelman A, Koziol J, Mahoney L, Maxwell C, Mckenzie M. The Rhode Island community responds to opioid overdose deaths. Rhode Island Medical Journal. 2014;97(10):34–37. [PubMed: 25271658]

71.

Substance Abuse and Mental Health Administration. National Recovery Month. [June 20, 2016]. (n.d.) Retrieved from http://www​.recoverymonth.gov/

72.

National Safety Council. Prescription drug community action kit: Public education and media. Washington, DC: National Safety Council; 2015.

73.

Centers for Disease Control and Prevention. HIV and injection drug use in the United States. 2015. [April 6, 2016]. Retrieved from http://www​.cdc.gov/hiv/risk/idu.html.

74.

Centers for Disease Control and Prevention. HIV surveillance report, 2014. Atlanta, GA: Centers for Disease Control and Prevention; 2014. [April 6, 2016]. Retrieved from http://www​.cdc.gov/hiv​/pdf/library/reports​/surveillance/cdc-hiv-surveillance-report-us.pdf.

75.

Centers for Disease Control and Prevention. Surveillance for viral hepatitis – United States, 2014. 2016. [July 28, 2016]. Retrieved from https://www​.cdc.gov/hepatitis​/statistics​/2014surveillance/index.htm.

76.

Ingram M. Master's thesis. Georgetown University; Washington, DC: 2014. [April 12, 2016]. The impact of syringe and needle exchange programs on drug use rates in the United States. Retrieved from https://repository​.library​.georgetown.edu​/bitstream/handle/10822​/709897/Ingram_georgetown​_0076M_12592.pdf?sequence=1.

77.

Rich JD, Adashi EY. Ideological anachronism involving needle and syringe exchange programs: Lessons from the Indiana HIV outbreak. JAMA. 2015;314(1):23–24. [PMC free article: PMC4496270] [PubMed: 26000661]

78.

Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E, Hutchinson SJ. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: A systematic review and meta-analysis. International Journal of Epidemiology. 2014;43(1):235–248. [PubMed: 24374889]

79.

Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D. Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: A review of reviews. Addiction. 2010;105(5):844–859. [PubMed: 20219055]

80.

National Institute on Drug Abuse. Overdose death rates. 2015. [January 25, 2016]. Retrieved from http://www​.drugabuse​.gov/related-topics/trends-statistics​/overdose-death-rates.

81.

Cowan K. CVS pharmacies in NY to sell naloxone without prescription. 2016. [April 11, 2016]. Retrieved from http://cnycentral​.com​/news/local/cvs-pharmacies-in-ny-to-sell-naloxone-without-prescription.

82.

StopOverdose​.org. Naloxone (Narcan®): Frequently asked questions. [January 25, 2016]. (n.d.) Retrieved from http://stopoverdose​.org/faq.htm.

83.

European Monitoring Centre for Drugs and Drug Addiction. Preventing fatal overdoses: A systematic review of the effectiveness of take-home naloxone. Luxembourg: EMCDDA Papers, Publications Office of the European Union; 2015.

84.

Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ozonoff A. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ. 2013;346(f174) [PMC free article: PMC4688551] [PubMed: 23372174]

85.

National Institute on Drug Abuse. Principles of drug addiction treatment: A research-based guide. Rockville, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2012. (NIH Publication No. 12–4180)

86.

Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: Options for critical response to the epidemic of opioid overdose mortality. The American Journal of Public Health. 2009;99(3):402–407. [PMC free article: PMC2661437] [PubMed: 19150908]

87.

American Society of Addiction Medicine. The ASAM standards of care for the addiction specialist physician. Chevy Chase, MD: American Society of Addiction Medicine; 2014.

88.

Mark TL, Dilonardo JD, Chalk M, Coffey RM. Trends in inpatient detoxification services, 1992-1997. Journal of Substance Abuse Treatment. 2002;23(4):253–260. [PubMed: 12495787]

89.

Mark TL, Vandivort-Warren R, Montejano LB. Factors affecting detoxification readmission: Analysis of public sector data from three states. Journal of Substance Abuse Treatment. 2006;31(4):439–445. [PubMed: 17084799]

90.

Lee MT, Horgan CM, Garnick DW, Acevedo A, Panas L, Ritter GA, Reynolds M. A performance measure for continuity of care after detoxification: Relationship with outcomes. Journal of Substance Abuse Treatment. 2014;47(2):130–139. [PMC free article: PMC4096006] [PubMed: 24912862]

91.

Millette S. Treatment for substance use disorders – The continuum of care. National Partnership on Alcohol Misuse and Crime. 2013

92.

National Institute on Drug Abuse. Principles of adolescent substance use disorder treatment: A research-based guide. Rockville, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2014. (NIH Publication No. 14-7953)

93.

Gastfriend DR, Mee-Lee D. The ASAM patient placement criteria: Context, concepts and continuing development. Journal of Addictive Diseases. 2004;22(Suppl 1):1–8. [PubMed: 15991586]

94.

Stallvik M, Gastfriend DR, Nordahl HM. Matching patients with substance use disorder to optimal level of care with the ASAM criteria software. Journal of Substance Use. 2015;20(6):389–398.

95.

The American Society of Addiction Medicine (ASAM). Continuum: The ASAM criteria decision engine. [April 4, 2016]. (n.d.) Retrieved from http:​//asamcontinuum.org/

96.

Substance Abuse and Mental Health Services Administration. Trauma-informed care in behavioral health services. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. (Treatment Improvement Protocol (TIP) Series, No. 57). (HHS Publication No (SMA) 13-4801)

97.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

98.

McLellan AT, Luborsky L, O'Brien CP, Woody GE. An improved diagnostic instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous & Mental Diseases. (168):26–33. (n.d.) [PubMed: 7351540]

99.

Cottler LB. Composite international diagnostic interview—Substance Abuse Module (SAM). St. Louis, MO: Washington University School of Medicine, Department of Psychiatry; 2000. [July 27, 2016]. Retrieved from http://pubs​.niaaa.nih​.gov/publications/AssessingAlcohol​/InstrumentPDFs/65_SAM​.pdf.

100.

Hasin D, Samet S. Psychiatric Research Interview for Substance and Mental Disorders (PRISM). New York, NY: New York State Psychiatric Institute; [January 27, 2016]. (n.d.) Retrieved from http://pubs​.niaaa.nih​.gov/publications/AssessingAlcohol​/InstrumentPDFs/52_PRISM​.pdf.

101.

Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addictive Behaviors. 2012;37(1):11–24. [PMC free article: PMC3196788] [PubMed: 21981788]

102.

Center for Substance Abuse Treatment. Clinical issues in intensive outpatient treatment. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2006. Chapter 10. Addressing diverse populations in intensive outpatient treatment. (Treatment improvement protocol (TIP) series, No. 47).

103.

Prendergast ML, Messina NP, Hall EA, Warda US. The relative effectiveness of women-only and mixed-gender treatment for substance-abusing women. Journal of Substance Abuse Treatment. 2011;40(4):336–348. [PMC free article: PMC3081899] [PubMed: 21315540]

104.

Messina N, Grella CE, Cartier J, Torres S. A randomized experimental study of gender-responsive substance abuse treatment for women in prison. Journal of Substance Abuse Treatment. 2010;38(2):97–107. [PMC free article: PMC2815183] [PubMed: 20015605]

105.

Wisdom JP, Pollock MN, Hopping-Winn A. Service engagement and retention for women with substance use disorders. Berkeley, CA: National Abandoned Infants Assistance Resource Center, University of California, Berkeley; 2011.

106.

Sheedy CK, Whitter M. Guiding principles and elements of recovery-oriented systems of care: What do we know from the research? Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2009. (HHS Publication No (SMA) 09-4439)

107.

Greenfield SF, Grella CE. What is “women-focused” treatment for substance use disorders? Psychiatric Services. 2009;60(7):880–882. [PMC free article: PMC2753530] [PubMed: 19564216]

108.

Coyhis D, Simonelli R. The Native American healing experience. Substance Use & Misuse. 2008;43(12-13):1927–1949. [PubMed: 19016172]

109.

Guerrero EG, Marsh JC, Duan L, Oh C, Perron B, Lee B. Disparities in completion of substance abuse treatment between and within racial and ethnic groups. Health Services Research. 2013;48(4):1450–1467. [PMC free article: PMC3725534] [PubMed: 23350871]

110.

Guerrero EG, Marsh JC, Khachikian T, Amaro H, Vega WA. Disparities in Latino substance use, service use, and treatment: Implications for culturally and evidence-based interventions under health care reform. Drug and Alcohol Dependence. 2013;133(3):805–813. [PubMed: 23953657]

111.

Jones JH, Treiber LA, Jones MC. Intervening at the intersection of medication adherence and health literacy. The Journal for Nurse Practitioners. 2014;10(8):527–534.

112.

Alegría M, Alvarez K, Ishikawa RZ, DiMarzio K, McPeck S. Removing obstacles to eliminating racial and ethnic disparities in behavioral health care. Health Affairs. 2016;35(6):991–999. [PMC free article: PMC5027758] [PubMed: 27269014]

113.

Senreich E. Are specialized LGBT program components helpful for gay and bisexual men in substance abuse treatment? Substance Use & Misuse. 2010;45(7-8):1077–1096. [PubMed: 20441452]

114.

Saloner B, Le Cook B. Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Affairs. 2013;32(1):135–145. [PMC free article: PMC3570982] [PubMed: 23297281]

115.

Substance Abuse and Mental Health Services Administration. Disaster planning handbook for behavioral health treatment programs. Technical Assistance Publication (TAP) Series, No. 34. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. (HHS Publication No (SMA) 13-4779)

116.

National Institute on Drug Abuse. DrugFacts: Treatment approaches for drug addiction. 2016. Retrieved from http://www​.drugabuse​.gov/publications/drugfacts​/treatment-approaches-drug-addiction.

117.

Kleber HD, Weiss RD, Anton RF, George TP, Greenfield SF, Kosten TR, Smith Connery H. Practice guideline for the treatment of patients with substance use disorders. Arlington, VA: American Psychiatric Association; 2006.

118.

Food and Drug Administration. Suboxone®: Highlights of prescribing information. 2015. [July 8, 2016]. Retrieved from http://www​.accessdata​.fda.gov/drugsatfda_docs​/label/2015/022410s020s022lbl.pdf.

119.

Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. (HHS Publication No (SMA) PEP15-FEDGUIDEOTP)

120.

Lee J, Kresina TF, Campopiano M, Lubran R, Clark HW. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. BioMed Research International, 2015. 2015 [PMC free article: PMC4299453] [PubMed: 25629034]

121.

Bonhomme J, Shim RS, Gooden R, Tyus D, Rust G. Opioid addiction and abuse in primary care practice: a comparison of methadone and buprenorphine as treatment options. Journal of the National Medical Association. 2012;104(7-8):342–350. [PMC free article: PMC4039205] [PubMed: 23092049]

122.

Kresina TF, Melinda C, Lee J, Ahadpour M, Robert L. Reducing mortality of people who use opioids through medication assisted treatment for opioid dependence. Journal of HIV & Retro Virus. 2015;1(1)

123.

Schwartz RP, Gryczynski J, O'Grady KE, Sharfstein JM, Warren G, Olsen Y, Jaffe JH. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. American Journal of Public Health. 2013;103(5):917–922. [PMC free article: PMC3670653] [PubMed: 23488511]

124.

Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews. 2014;2 [PMC free article: PMC10617756] [PubMed: 24500948]

125.

National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Effective medical treatment of opiate addiction. JAMA. 1998;280(22):1936–1943. [PubMed: 9851480]

126.

Joseph H, Stancliff S, Langrod J. Methadone maintenance treatment (MMT): A review of historical and clinical issues. Mount Sinai Journal of Medicine. 2000;67(5-6):347–364. [PubMed: 11064485]

127.

Kreek MJ, Borg L, Ducat E, Ray B. Pharmacotherapy in the treatment of addiction: Methadone. Journal of Addictive Diseases. 2010;29(2):200–216. [PMC free article: PMC2885886] [PubMed: 20407977]

128.

Perkins ME, Bloch HI. Survey of a methadone maintenance treatment program. American Journal of Psychiatry. 1970;126(10):1389–1396. [PubMed: 5434621]

129.

Fiellin DA, Friedland GH, Gourevitch MN. Opioid dependence: Rationale for and efficacy of existing and new treatments. Clinical Infectious Diseases. 2006;43(Suppl 4):S173–S177. [PubMed: 17109303]

130.

Anderson IB, Kearney TE. Use of methadone. Western Journal of Medicine. 2000;172(1):43–46. [PMC free article: PMC1070723] [PubMed: 10695444]

131.

Säwe J, Hansen J, Ginman C, Hartvig P, Jakobsson P, Nilsson M, Anggård E. Patient-controlled dose regimen of methadone for chronic cancer pain. BMJ. 1981;282(6266):771–773. [PMC free article: PMC1504645] [PubMed: 6163497]

132.

Sees KL, Delucchi KL, Masson C, Rosen A, Clark HW, Robillard H, Hall SM. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. JAMA. 2000;283(10):1303–1310. [PubMed: 10714729]

133.

Fullerton CA, Kim M, Thomas CP, Lyman DR, Montejano LB, Dougherty RH, Delphin-Rittmon ME. Medication-assisted treatment with methadone: Assessing the evidence. Psychiatric Services. 2014;65(2):146–157. [PubMed: 24248468]

134.

Connock M, Juarez-Garcia A, Jowett S, Frew E, Liu Z, Taylor RJ, Taylor RS. Methadone and buprenorphine for the management of opioid dependence: A systematic review and economic evaluation. Health Technology Assessment. 2007;11(9):1–171. [PubMed: 17313907]

135.

Stotts AL, Dodrill CL, Kosten TR. Opioid dependence treatment: Options in pharmacotherapy. Expert Opinion on Pharmacotherapy. 2009;10(11):1727–1740. [PMC free article: PMC2874458] [PubMed: 19538000]

136.

Substance Abuse and Mental Health Services Administration. National Survey of Substance Abuse Treatment Services (N-SSATS): 2013 Data on substance abuse treatment facilities. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. (BHSIS Series S-73, HHS Publication No (SMA) 14-4890)

137.

Stancliff S, Joseph H, Fong C, Furst T, Comer SD, Roux P. Opioid maintenance treatment as a harm reduction tool for opioid-dependent individuals in New York City: The need to expand access to buprenorphine/naloxone in marginalized populations. Journal of Addictive Diseases. 2012;31(3):278–287. [PMC free article: PMC3620719] [PubMed: 22873189]

138.

Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine. 2014;370(22):2063–2066. [PubMed: 24758595]

139.

Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction in opioid treatment programs. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005. (Treatment Improvement Protocol (TIP) Series, No. 43). (HHS Publication No (SMA) 12-4214)

140.

Thomas CP, Fullerton CA, Kim M, Montejano L, Lyman DR, Dougherty RH, Delphin-Rittmon ME. Medication-assisted treatment with buprenorphine: Assessing the evidence. Psychiatric Services. 2014;65(2):158–170. [PubMed: 24247147]

141.

Pathan H, Williams J. Basic opioid pharmacology: An update. British Journal of Pain. 2012;6(1):11–16. [PMC free article: PMC4590096] [PubMed: 26516461]

142.

Schuman-Olivier Z, Albanese M, Nelson SE, Roland L, Puopolo F, Klinker L, Shaffer HJ. Self-treatment: Illicit buprenorphine use by opioid-dependent treatment seekers. Journal of Substance Abuse Treatment. 2010;39(1):41–50. [PubMed: 20434868]

143.

Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. Factors contributing to the rise of buprenorphine misuse: 2008 - 2013. Drug and Alcohol Dependence. 2014;142:98–104. [PubMed: 24984689]

144.

Monico LB, Mitchell SG, Gryczynski J, Schwartz RP, O'Grady KE, Olsen YK, Jaffe JH. Prior experience with non-prescribed buprenorphine: Role in treatment entry and retention. Journal of Substance Abuse Treatment. 2015;57:57–62. [PMC free article: PMC4561018] [PubMed: 25980599]

145.

Jacobs P, Ang A, Hillhouse MP, Saxon AJ, Nielsen S, Wakim PG, Blaine JD. Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories. The American Journal on Addictions. 2015;24(7):667–675. [PMC free article: PMC5322942] [PubMed: 26400835]

146.

Center for Substance Abuse Treatment. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. (Treatment improvement protocol (TIP) series, No. 40).

147.

Medication assisted treatment for opioid use disorders. Fed. Reg. Jul 8, 2016. p. 44712. (to be codified at 42 C.F.R. pt 8)

148.

The Henry J. Kaiser Family Foundation. Primary care physicians by field. 2015. [July 27, 2016]. Retrieved from http://kff​.org/other​/state-indicator/primary-care-physicians-by-field/

149.

Stein BD, Pacula RL, Gordon AJ, Burns RM, Leslie DL, Sorbero MJ, Dick AW. Where is buprenorphine dispensed to treat opioid use disorders? The role of private offices, opioid treatment programs, and substance abuse treatment facilities in urban and rural counties. Milbank Quarterly. 2015;93(3):561–583. [PMC free article: PMC4567853] [PubMed: 26350930]

150.

Sigmon SC. The untapped potential of office-based buprenorphine treatment. JAMA Psychiatry. 2015;72(4):395–396. [PubMed: 25671806]

151.

Substance Abuse and Mental Health Services Administration. The facts about naltrexone for treatment of opioid addiction. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2009. (HHS Publication No (SMA) 15-4444)

152.

Substance Abuse and Mental Health Services Administration. An introduction to extended-release injectable naltrexone for the treatment of people with opioid dependence. SAMHSA Advisory. 2012;11(1)

153.

Substance Abuse and Mental Health Services Administration. Clinical use of extended-release injectable naltrexone in the treatment of opioid use disorder: A brief guide. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. (HHS Publication No (SMA) 14-4892R)

154.

Miller PM, Book SW, Stewart SH. Medical treatment of alcohol dependence: A systematic review. The International Journal of Psychiatry in Medicine. 2011;42(3):227–266. [PMC free article: PMC3632430] [PubMed: 22439295]

155.

National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: A clinician's guide. 2005. [March 20, 2015]. Retrieved from http://pubs​.niaaa.nih​.gov/publications/Practitioner​/CliniciansGuide2005​/clinicians_guide.htm.

156.

Substance Abuse and Mental Health Services Administration & National Institute on Alcohol Abuse and Alcoholism. Medication for the treatment of alcohol use disorder: A brief guide. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. (HHS Publication No (SMA) 15-4907)

157.

Lin SK. Pharmacological means of reducing human drug dependence: A selective and narrative review of the clinical literature. The British Journal of Clinical Pharmacology. 2014;77(2):242–252. [PMC free article: PMC4014026] [PubMed: 23701272]

158.

National Council on Alcoholism and Drug Dependence. NCADD's consumer guide to medication-assisted recovery. New York, NY: National Council on Alcohol and Drug Dependence, Inc; (n.d.)

159.

Kufahl PR, Watterson LR, Olive MF. The development of acamprosate as a treatment against alcohol relapse. Expert Opinion on Drug Discovery. 2014;9(11):1355–1369. [PMC free article: PMC4578640] [PubMed: 25258174]

160.

Zindel LR, Kranzler HR. Pharmacotherapy of alcohol use disorders: Seventy-five years of progress. Journal of Studies on Alcohol and Drugs. 2014;75(Suppl 17):79–88. [PMC free article: PMC4453501] [PubMed: 24565314]

161.

Chick J, Gough K, Falkowski W, Kershaw P, Hore B, Mehta B, Torley D. Disulfiram treatment of alcoholism. The British Journal of Psychiatry. 1992;161(1):84–89. [PubMed: 1638335]

162.

Vuittonet CL, Halse M, Leggio L, Fricchione SB, Brickley M, Haass-Koffler CL, Kenna GA. Pharmacotherapy for alcoholic patients with alcoholic liver disease. American Journal of Health-System Pharmacy. 2014;71(15):1265–1276. [PMC free article: PMC4170837] [PubMed: 25027533]

163.

alcoholrehab​.com. Naltrexone and alcohol rehab. [January 25, 2016]. (n.d.) Retrieved from http://alcoholrehab​.com​/drug-addiction-treatment​/opiate-antagonist-naltrexone-alcohol-rehab/

164.

Mannelli P, Peindl K, Masand PS, Patkar AA. Long-acting injectable naltrexone for the treatment of alcohol dependence. Expert Review of Neurotherapeutics. 2007;7(10):1265–1277. [PubMed: 17939765]

165.

Rösner S, Hackl-Herrwerth A, Leucht S, Lehert P, Vecchi S, Soyka M. Acamprosate for alcohol dependence. The Cochrane Database of Systematic Reviews. 2010;9 [PubMed: 20824837]

166.

Jonas DE, Amick HR, Feltner C, et al. Bobashev G, Thomas K, Garbutt JC. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. JAMA. 2014;311(18):1889–1900. [PubMed: 24825644]

167.

Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Addiction. 2013;108(2):275–293. [PMC free article: PMC3970823] [PubMed: 23075288]

168.

Substance Abuse and Mental Health Services Administration. Report to Congress on the nation's substance abuse and mental health workforce issues. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

169.

McGovern MP. Evidence-based practices for substance use disorders. Psychiatric Clinics of North America. 2003;26(4):991–1010. [PMC free article: PMC3678283] [PubMed: 14711132]

170.

Center for Substance Abuse Treatment. Substance abuse treatment: Group therapy. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005. (Treatment improvement protocol (TIP) series, No. 41).

171.

Wandersman A, Imm P, Chinman M, Kaftarian S. Getting to outcomes: A results-based approach to accountability. Evaluation and Program Planning. 2000;23(3):389–395.

172.

Morgenstern J, Blanchard KA, Morgan TJ, Labouvie E, Hayaki J. Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: Within treatment and posttreatment findings. Journal of Consulting and Clinical Psychology. 2001;69(6):1007–1017. [PubMed: 11777104]

173.

Carroll KM, Onken LS. Behavioral therapies for drug abuse. Journal of the American Psychiatric Association. 2005;162(8):1452–1460. [PMC free article: PMC3633201] [PubMed: 16055766]

174.

McHugh RK, Hearon BA, Otto MW. Cognitive-behavioral therapy for substance use disorders. Psychiatric Clinics of North America. 2010;33(3):511–525. [PMC free article: PMC2897895] [PubMed: 20599130]

175.

Gregory VL. Cognitive-behavioral therapy for comorbid bipolar and substance use disorders: A systematic review of controlled trials. Mental Health and Substance Use. 2011;4(4):302–313.

176.

Quello SB, Brady KT, Sonne SC. Mood disorders and substance use disorder: A complex comorbidity. Science & Practice Perspectives. 2005;3(1):13–21. [PMC free article: PMC2851027] [PubMed: 18552741]

177.

Higgins ST, Heil SH, Sigmon SC. Voucher-based contingency management in the treatment of substance use disorders. In: Madden GJ, Dube WV, Hackenberg TD, Hanley GP, Lattal KA, editors. APA handbook of behavior analysis, Vol. 2: Translating principles into practice. Washington, DC, US: American Psychological Association; 2013. pp. 481–500.

178.

Carroll KM, Nich C, Petry NM, Eagan DA, Shi JM, Ball SA. A randomized factorial trial of disulfiram and contingency management to enhance cognitive behavioral therapy for cocaine dependence. Drug and Alcohol Dependence. 2016;160:135–142. [PMC free article: PMC4767616] [PubMed: 26817621]

179.

Carroll KM, Easton CJ, Nich C, Hunkele KA, Neavins TM, Sinha R, Rounsaville BJ. The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology. 2006;74(5):955–966. [PMC free article: PMC2148500] [PubMed: 17032099]

180.

Secades-Villa R, Garcia-Rodriguez O, Garcia-Fernandez G, Sanchez-Hervas E, Fernandez-Hermida JR, Higgins ST. Community reinforcement approach plus vouchers among cocaine-dependent outpatients: Twelve-month outcomes. Psychology of Addictive Behaviors. 2011;25(1):174–179. [PubMed: 21261406]

181.

Dennis M, Godley SH, Diamond G, Tims FM, Babor T, Donaldson J, Webb C. The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment. 2004;27(3):197–213. [PubMed: 15501373]

182.

Slesnick N, Prestopnik JL, Meyers RJ, Glassman M. Treatment outcome for street-living, homeless youth. Addictive Behaviors. 2007;32(6):1237–1251. [PMC free article: PMC1894944] [PubMed: 16989957]

183.

Burlew AK, Montgomery L, Kosinski AS, Forcehimes AA. Does treatment readiness enhance the response of African American substance users to motivational enhancement therapy? Psychology of Addictive Behaviors. 2013;27(3):744–753. [PMC free article: PMC4220415] [PubMed: 23421576]

184.

Miles LA. Motivational enhancement therapy: Treatment for substance abuse & more. 2015. [April 4, 2016]. Retrieved from http://psychcentral​.com​/blog/archives/2013​/07/12/motivational-enhancement-therapy-treatment-for-substance-abuse-more/

185.

Tevyaw TOL, Monti PM. Motivational enhancement and other brief interventions for adolescent substance abuse: Foundations, applications and evaluations. Addiction. 2004;99(s2):63–75. [PubMed: 15488106]

186.

Helstrom A, Hutchison K, Bryan A. Motivational enhancement therapy for high-risk adolescent smokers. Addictive Behaviors. 2007;32(10):2404–2410. [PMC free article: PMC2082126] [PubMed: 17428617]

187.

Rawson RA, Gonzales R, Pearce V, Ang A, Marinelli-Casey P, Brummer J. Methamphetamine dependence and HIV risk behavior. Journal of Substance Abuse Treatment. 2008;35(3):279–284. [PMC free article: PMC2630179] [PubMed: 18329225]

188.

Shoptaw S, Reback CJ. Methamphetamine use and infectious disease-related behaviors in men who have sex with men: Implications for interventions. Addiction. 2007;102(Suppl 1):130–135. [PubMed: 17493062]

189.

Substance Abuse and Mental Health Services Administration. Using matrix with women clients: A supplement to the matrix intensive outpatient treatment for people with stimulant use disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. (HHS Pub No (SMA) 12-4698)

190.

Walitzer KS, Dermen KH, Barrick C. Facilitating involvement in Alcoholics Anonymous during out-patient treatment: A randomized clinical trial. Addiction. 2009;104(3):391–401. [PMC free article: PMC2802221] [PubMed: 19207347]

191.

Kaskutas LA, Subbaraman MS, Witbrodt J, Zemore SE. Effectiveness of making Alcoholics Anonymous easier: A group format 12-step facilitation approach. Journal of Substance Abuse Treatment. 2009;37(3):228–239. [PMC free article: PMC2746399] [PubMed: 19339148]

192.

Crits-Christoph P, Siqueland L, Blaine J, Frank A, Luborsky L, Onken LS, Beck AT. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry. 1999;56(6):493–502. [PubMed: 10359461]

193.

Allen JP, Mattson ME, Miller WR, Tonigan JS, Connors GJ, Rychtarik RG, Litt M. Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol. 1997;58(1):7–29. [PubMed: 8979210]

194.

Litt MD, Kadden RM, Kabela-Cormier E, Petry NM. Changing network support for drinking: Network support project 2-year follow-up. Journal of Consulting and Clinical Psychology. 2009;77(2):229–242. [PMC free article: PMC2661035] [PubMed: 19309183]

195.

Timko C, DeBenedetti A. A randomized controlled trial of intensive referral to 12-step self-help groups: One-year outcomes. Drug and Alcohol Dependence. 2007;90(2):270–279. [PubMed: 17524574]

196.

Longabaugh R, Wirtz PW, Zweben A, Stout RL. Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction. 1998;93(9):1313–1333. [PubMed: 9926538]

197.

Thevos AK, Thomas SE, Randall CL. Social support in alcohol dependence and social phobia: Treatment comparisons. Research on Social Work Practice. 2001;11(4):458–472.

198.

Cooney NL, Babor TF, DiClemente CC, Del Boca FK. Clinical and scientific implications of Project MATCH. In: Babor TF, Boca FKD, editors. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press; 2003. pp. 222–237.

199.

Donovan DM, Daley DC, Brigham GS, Hodgkins CC, Perl HI, Garrett S, Zammarelli L. Stimulant abuser groups to engage in 12-step (STAGE-12): A multisite trial in the NIDA clinical trials network. Journal of Substance Abuse Treatment. 2013;44(1):103–114. [PMC free article: PMC3434261] [PubMed: 22657748]

200.

Yalom ID, Leszcz M. Theory and practice of group psychotherapy. 5 ed. New York, NY: Basic Books; 2005.

201.

Humphreys K. Tale telling in an alcohol mutual help organization. New Directions in Alcohol Studies. 2004;29:33–44.

202.

Labbe AK, Slaymaker V, Kelly JF. Toward enhancing 12-step facilitation among young people: A systematic qualitative investigation of young adults' 12-step experiences. Substance Abuse. 2014;35(4):399–407. [PMC free article: PMC4268407] [PubMed: 25102256]

203.

Kelly JF, Magill M, Stout RL. How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous. Addiction Research & Theory. 2009;17(3):236–259.

204.

White WL, Kelly JF, Roth JD. New addiction-recovery support institutions: Mobilizing support beyond professional addiction treatment and recovery mutual aid. Journal of Groups in Addiction & Recovery. 2012;7(2-4):297–317.

205.

Hester RK, Lenberg KL, Campbell W, Delaney HD. Overcoming addictions, a web-based application, and SMART recovery, an online and in-person mutual help group for problem drinkers, Part 1: Three-month outcomes of a randomized controlled trial. Journal of Medical Internet Research. 2013;15(7):11–25. [PMC free article: PMC3713880] [PubMed: 23846588]

206.

Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, McCulloch D. Increasing diabetes self-management education in community settings: A systematic review. American Journal of Preventive Medicine. 2002;22(Suppl 4):39–66. [PubMed: 11985934]

207.

Donohue B, Azrin N, Allen DN, Romero V, Hill HH, Tracy K, Van Hasselt VB. Family behavior therapy for substance abuse and other associated problems: A review of its intervention components and applicability. Behavior Modification. 2009;33(5):495–519. [PubMed: 19592601]

208.

Winters J, Fals-Stewart W, O'Farrell TJ, Birchler GR, Kelley ML. Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment. Journal of Consulting and Clinical Psychology. 2002;70(2):344–355. [PubMed: 11952192]

209.

Stanton D, Heath A. Family/couples approaches to treatment engagement and therapy. In: Lowinson JH, Ruiz P, editors. Substance abuse: A comprehensive textbook. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.

210.

O'Farrell TJ, Clements K. Review of outcome research on marital and family therapy in treatment for alcoholism. Journal of Marital & Family Therapy. 2012;38:122–144. [PMC free article: PMC3270890] [PubMed: 22283384]

211.

Center for Behavioral Health Statistics and Quality. The NSDUH Report: Adults with mental illness or substance use disorder account for 40 percent of all cigarettes smoked. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

212.

Baca CT, Yahne CE. Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment. 2009;36(2):205–219. [PubMed: 18715746]

213.

Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology. 2004;72(6):1144–1156. [PubMed: 15612860]

214.

Substance Abuse and Mental Health Administration. Recovery and recovery support. 2015. [June 22, 2016]. Retrieved from http://www​.samhsa.gov/recovery.

215.

Ruiz BS, Korchmaros JD, Greene A, Hedges K. Evidence-based substance abuse treatment for adolescents: Engagement and outcomes. Practice: Social Work in Action. 2011;23(4):215–233.

216.

National Council for Community Behavioral Healthcare. HIT adoption and readiness for meaningful use in community behavioral health: Report on the 2012 National Council Survey. Washington, DC: National Council for Community Behavioral Healthcare; 2012.

217.

Health Resources and Services Administration. What is telehealth? [April 11, 2016]. (n.d.) Retrieved from http://www​.hrsa.gov/healthit​/toolbox/RuralHealthITtoolbox​/Telehealth​/whatistelehealth.html.

218.

Kiluk BD, Carroll KM. New developments in behavioral treatments for substance use disorders. Current Psychiatry Reports. 2013;15(12):1–14. [PMC free article: PMC3878068] [PubMed: 24173656]

219.

Olmstead TA, Ostrow CD, Carroll KM. Cost-effectiveness of computer-assisted training in cognitive-behavioral therapy as an adjunct to standard care for addiction. Drug and Alcohol Dependence. 2010;110(3):200–207. [PMC free article: PMC3033701] [PubMed: 20392575]

220.

Marsch LA, Dallery J. Advances in the psychosocial treatment of addiction: The role of technology in the delivery of evidence-based psychosocial treatment. The Psychiatric Clinics of North America. 2012;35(2):481–493. [PMC free article: PMC3362794] [PubMed: 22640767]

221.

Rosa C, Campbell ANC, Miele GM, Brunner M, Winstanley EL. Using e-technologies in clinical trials. Contemporary Clinical Trials. 2015;45:41–54. [PMC free article: PMC4648297] [PubMed: 26176884]

222.

Johnson K, Isham A, Shah DV, Gustafson DH. Potential roles for new communication technologies in treatment of addiction. Current Psychiatry Reports. 2011;13(5):390–397. [PMC free article: PMC3179375] [PubMed: 21739171]

223.

Anderson M. Technology device ownership: 2015. 2015. [June 10, 2016]. Retrieved from http://www​.pewinternet​.org/2015/10/29/technology-device-ownership-2015.

224.

Anderson M, Perrin A. 15% of Americans don't use the internet. Who are they? 2015. [June 10, 2016]. Retrieved from http://www​.pewresearch​.org/fact-tank/2015​/07/28/15-of-americans-dont-use-the-internet-who-are-they/

225.

Kiluk BD, Sugarman DE, Nich C, Gibbons CJ, Martino S, Rounsaville BJ, Carroll KM. A methodological analysis of randomized clinical trials of computer-assisted therapies for psychiatric disorders: Toward improved standards for an emerging field. American Journal of Psychiatry. 2011;168(8):790–799. [PMC free article: PMC3607199] [PubMed: 21536689]

226.

Marsch LA, Guarino H, Acosta M, Aponte-Melendez Y, Cleland C, Grabinski M, Edwards J. Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment. Journal of Substance Abuse Treatment. 2014;46(1):43–51. [PMC free article: PMC3839618] [PubMed: 24060350]

227.

King VL, Brooner RK, Peirce JM, Kolodner K, Kidorf MS. A randomized trial of Web-based videoconferencing for substance abuse counseling. Journal of Substance Abuse Treatment. 2014;46(1):36–42. [PMC free article: PMC3818495] [PubMed: 24035556]

228.

Gustafson DH, McTavish FM, Chih MY, Atwood AK, Johnson RA, Boyle MG, Shah D. A smartphone application to support recovery from alcoholism: A randomized clinical trial. JAMA Psychiatry. 2014;71(5):566–572. [PMC free article: PMC4016167] [PubMed: 24671165]

229.

Carroll KM, Kiluk BD, Nich C, Gordon MA, Portnoy GA, Marino DR, Ball SA. Computer-assisted delivery of cognitive-behavioral therapy: Eficacy and durability of CBT4CBT among cocaine-dependent individuals maintained on methadone. American Journal of Psychiatry. 2014;171(4):436–444. [PMC free article: PMC4042674] [PubMed: 24577287]

230.

Hasin DS, Aharonovich E, O'Leary A, Greenstein E, Pavlicova M, Arunajadai S, Johnston B. Reducing heavy drinking in HIV primary care: A randomized trial of brief intervention, with and without technological enhancement. Addiction. 2013;108(7):1230–1240. [PMC free article: PMC3755729] [PubMed: 23432593]

231.

Rooke S, Copeland J, Norberg M, Hine D, McCambridge J. Effectiveness of a self-guided web-based cannabis treatment program: Randomized controlled trial. Journal of Medical Internet Research. 2013;15(2):e26. [PMC free article: PMC3636012] [PubMed: 23470329]

232.

Kay-Lambkin FJ, Baker AL, Kelly B, Lewin TJ. Clinician-assisted computerised versus therapist-delivered treatment for depressive and addictive disorders: A randomised controlled trial. Medical Journal of Australia. 2011;195(3):S44–S50. [PubMed: 21806518]

233.

Campbell AN, Nunes EV, Matthews AG, Stitzer M, Miele GM, Polsky D, Ghitza UE. Internet-delivered treatment for substance abuse: A multisite randomized controlled trial. Journal of the American Psychiatric Association. 2014;171(6):683–690. [PMC free article: PMC4079279] [PubMed: 24700332]

234.

Cunningham JA, Wild TC, Cordingley J, Van Mierlo T, Humphreys K. A randomized controlled trial of an internet-based intervention for alcohol abusers. Addiction. 2009;104(12):2023–2032. [PMC free article: PMC2779998] [PubMed: 19922569]

235.

Kypri K, McCambridge J, Vater T, Bowe SJ, Saunders JB, Cunningham JA, Horton NJ. Web-based alcohol intervention for Mäori university students: Double-blind, multi-site randomized controlled trial. Addiction. 2013;108(2):331–338. [PMC free article: PMC3588153] [PubMed: 22925046]

236.

Hester RK, Delaney HD, Campbell W. The college drinker's check-up: Outcomes of two randomized clinical trials of a computer-delivered intervention. Psychology of Addictive Behaviors. 2012;26(1):1–12. [PMC free article: PMC3246033] [PubMed: 21823769]

237.

Walters ST, Vader AM, Harris TR. A controlled trial of web-based feedback for heavy drinking college students. Prevention Science. 2007;8(1):83–88. [PubMed: 17136461]

238.

Palfai T, Tahaney K, Winter M, Saitz R. Readiness-to-change as a moderator of a web-based brief intervention for marijuana among students identified by health center screening. Drug and Alcohol Dependence. 2016;161:368–371. [PMC free article: PMC5986176] [PubMed: 26948755]

239.

Hankin A, Haley L, Baugher A, Colbert K, Houry D. Kiosk versus in-person screening for alcohol and drug use in the emergency department: patient preferences and disclosure. Western Journal of Emergency Medicine. 2015;16(2):220–228. [PMC free article: PMC4380369] [PubMed: 25834660]

240.

Mello MJ, Longabaugh R, Baird J, Nirenberg T, Woolard R. DIAL: A telephone brief intervention for high-risk alcohol use with injured emergency department patients. Annals of Emergency Medicine. 2008;51(6):755–764. [PubMed: 18436341]

241.

McKay JR, Lynch KG, Shepard DS, Pettinati HM. The effectiveness of telephone-based continuing care for alcohol and cocaine dependence: 24-month outcomes. Archives of General Psychiatry. 2005;62(2):199–207. [PubMed: 15699297]

242.

Bewick BM, Trusler K, Barkham M, Hill AJ, Cahill J, Mulhern B. The effectiveness of web-based interventions designed to decrease alcohol consumption—A systematic review. Preventive Medicine. 2008;47(1):17–26. [PubMed: 18302970]

243.

Carey KB, Scott-Sheldon LA, Elliott JC, Bolles JR, Carey MP. Computer-delivered interventions to reduce college student drinking: A meta-analysis. Addiction. 2009;104(11):1807–1819. [PMC free article: PMC2763045] [PubMed: 19744139]

244.

Elliott JC, Carey KB, Bolles JR. Computer-based interventions for college drinking: A qualitative review. Addictive Behaviors. 2008;33(8):994–1005. [PMC free article: PMC2441945] [PubMed: 18538484]

245.

Kypri K, Saunders JB, Williams SM, McGee RO, Langley JD, Cashell-Smith ML, Gallagher SJ. Web-based screening and brief intervention for hazardous drinking: A double-blind randomized controlled trial. Addiction. 2004;99(11):1410–1417. [PubMed: 15500594]

246.

Neumann T, Neuner B, Weiss-Gerlach E, Tonnesen H, Gentilello LM, Wernecke KD, Spies CD. The effect of computerized tailored brief advice on at-risk drinking in subcritically injured trauma patients. Journal of Trauma and Acute Care Surgery. 2006;61(4):805–814. [PubMed: 17033544]

247.

Community Preventive Services Task Force. Preventing excessive alcohol consumption: Electronic screening and brief interventions (e-SBI). 2012. [June 10, 2016]. Retrieved from http://www​.thecommunityguide​.org/alcohol/RReSBI.html.

248.

Riper H, Kramer J, Conijn B, Smit F, Schippers G, Cuijpers P. Translating effective web-based self-help for problem drinking into the real world. Alcoholism: Clinical and Experimental Research. 2009;33(8):1401–1408. [PubMed: 19413646]

249.

Brief DJ, Rubin A, Keane TM, Enggasser JL, Roy M, Helmuth E, Rosenbloom D. Web intervention for OEF/OIF veterans with problem drinking and PTSD symptoms: A randomized clinical trial. Journal of Consulting and Clinical Psychology. 2013;81(5):890–900. [PMC free article: PMC9169869] [PubMed: 23875821]

250.

Litvin EB, Abrantes AM, Brown RA. Computer and mobile technology-based interventions for substance use disorders: An organizing framework. Addictive Behaviors. 2013;38(3):1747–1756. [PubMed: 23254225]

251.

Moore BA, Fazzino T, Garnet B, Cutter CJ, Barry DT. Computer-based interventions for drug use disorders: A systematic review. Journal of Substance Abuse Treatment. 2011;40(3):215–223. [PMC free article: PMC3073660] [PubMed: 21185683]

252.

Kiluk BD, Nich C, Babuscio T, Carroll KM. Quality vs. quantity: Acquisition of coping skills following computerized cognitive behavioral therapy for substance use disorders. Addiction. 2010;105(12):2120–2127. [PMC free article: PMC2975828] [PubMed: 20854334]

253.

Klein AA, Slaymaker VJ, Dugosh KL, McKay JR. Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment. 2012;42(1):25–34. [PMC free article: PMC6498848] [PubMed: 21862275]

254.

Davis TA, Ancis J. Look to the relationship: A review of African American women substance users' poor treatment retention and working alliance development. Substance Use & Misuse. 2012;47(6):662–672. [PubMed: 22329365]

255.

Substance Abuse and Mental Health Services Administration & Center for Behavioral Health Statistics and Quality. The NSDUH Report: Need for and receipt of substance use treatment among Hispanics. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012.

256.

Substance Abuse and Mental Health Services Administration & Center for Behavioral Health Statistics and Quality. Need for and receipt of substance use treatment among Blacks. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

257.

Longshore D, Grills C. Motivating illegal drug use recovery: Evidence for a culturally congruent intervention. Journal of Black Psychology. 2000;26(3):288–301.

258.

Gil AG, Wagner EF, Tubman JG. Culturally sensitive substance abuse intervention for Hispanic and African American adolescents: Empirical examples from the Alcohol Treatment Targeting Adolescents in Need (ATTAIN) project. Addiction. 2004;99(s2):140–150. [PubMed: 15488112]

259.

Milligan CO, Nich C, Carroll KM. Ethnic differences in substance abuse treatment retention, compliance, and outcome from two clinical trials. Psychiatric Services. 2004;55:167–173. [PMC free article: PMC3666311] [PubMed: 14762242]

260.

Tonigan JS. Project Match treatment participation and outcome by self-reported ethnicity. Alcoholism: Clinical & Experimental Research. 2003;27(8):1340–1344. [PubMed: 12966335]

261.

Witkiewitz K, Bowen S, Douglas H, Hsu SH. Mindfulness-based relapse prevention for substance craving. Addictive Behaviors. 2013;38(2):1563–1571. [PMC free article: PMC3408809] [PubMed: 22534451]

262.

Beckstead DJ, Lambert MJ, DuBose AP, Linehan M. Dialectical behavior therapy with American Indian/Alaska Native adolescents diagnosed with substance use disorders: Combining an evidence based treatment with cultural, traditional, and spiritual beliefs. Addictive Behaviors. 2015;51:84–87. [PubMed: 26240942]

263.

Niv N, Wong EC, Hser Y-I. Asian Americans in community-based substance abuse treatment: Service needs, utilization, and outcomes. Journal of Substance Abuse Treatment. 2007;33(3):313–319. [PubMed: 17376635]

264.

Yu J, Warner LA. Substance abuse treatment readmission patterns of Asian Americans: Comparisons with other ethnic groups. The American Journal of Drug and Alcohol Abuse. 2013;39(1):23–27. [PubMed: 22783932]

265.

Wu L-T, Blazer DG. Substance use disorders and co-morbidities among Asian Americans and Native Hawaiians/Pacific Islanders. Psychological Medicine. 2015;45(03):481–494. [PMC free article: PMC4272661] [PubMed: 25066115]

266.

Substance Abuse and Mental Health Services Administration & Center for Behavioral Health Statistics and Quality. Improving cultural competence. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. (Treatment Improvement Protocol (TIP) Series, No. 59). (HHS Publication No (SMA) 14-4849)

267.

Cochran BN, Cauce AM. Characteristics of lesbian, gay, bisexual, and transgender individuals entering substance abuse treatment. Journal of Substance Abuse Treatment. 2006;30(2):135–146. [PubMed: 16490677]

268.

McCabe SE, West BT, Hughes TL, Boyd CJ. Sexual orientation and substance abuse treatment utilization in the United States: Results from a national survey. Journal of Substance Abuse Treatment. 2013;44(1):4–12. [PMC free article: PMC3388170] [PubMed: 22444421]

269.

Ward BW, Dahlhamer JM, Galinsky AM, Joestl SS. Sexual orientation and health among US adults: National Health Interview Survey, 2013. National Health Statistics Reports. 2014;77:1–10. [PubMed: 25025690]

270.

Marshal MP, Friedman MS, Stall R, King KM, Miles J, Gold MA, Morse JQ. Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction. 2008;103(4):546–556. [PMC free article: PMC2680081] [PubMed: 18339100]

271.

Cochran BN, Peavy KM, Robohm JS. Do specialized services exist for LGBT individuals seeking treatment for substance misuse? A study of available treatment programs. Substance Use & Misuse. 2007;42(1):161–176. [PubMed: 17366131]

272.

Green KE, Feinstein BA. Substance use in lesbian, gay, and bisexual populations: An update on empirical research and implications for treatment. Psychology of Addictive Behaviors. 2012;26(2):265–278. [PMC free article: PMC3288601] [PubMed: 22061339]

273.

Lombardi EL, van Servellen G. Building culturally sensitive substance use prevention and treatment programs for transgendered populations. Journal of Substance Abuse Treatment. 2000;19(3):291–296. [PubMed: 11027900]

274.

Substance Abuse and Mental Health Administration. Veterans and military families. 2014. [June 9, 2016]. Retrieved from http://www​.samhsa.gov​/veterans-military-families.

275.

Hoggatt KJ, Jamison AL, Lehavot K, Cucciare MA, Timko C, Simpson TL. Alcohol and drug misuse, abuse, and dependence in women veterans. Epidemiologic Reviews. 2015;37:23–37. [PubMed: 25608962]

276.

Coker KL, Stefanovics E, Rosenheck R. Correlates of improvement in substance abuse among dually diagnosed veterans with post-traumatic stress disorder in specialized intensive VA treatment. Psychological Trauma: Theory, Research, Practice, and Policy. 2016;8(1):41–48. [PMC free article: PMC4487392] [PubMed: 26121176]

277.

Smelson DA, Kline A, Kuhn J, Rodrigues S, O'Connor K, Fisher W, Kane V. A wraparound treatment engagement intervention for homeless veterans with co-occurring disorders. Psychological Services. 2013;10(2):161–167. [PubMed: 23244030]

278.

The Pew Center on the States. One in 100: Behind bars in America 2008. Washington, DC: The Pew Charitable Trusts; 2008.

279.

Krinsky CS, Lathrop SL, Brown P, Nolte KB. Drugs, detention, and death: A study of the mortality of recently released prisoners. The American Journal of Forensic Medicine and Pathology. 2009;30(1):6–9. [PubMed: 19237844]

280.

Binswanger IA, Blatchford PJ, Mueller SR, Stern MF. Mortality after prison release: Opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Annals of Internal Medicine. 2013;159(9):592–600. [PMC free article: PMC5242316] [PubMed: 24189594]

281.

Møller LF, Matic S, van Den Bergh BJ, Moloney K, Hayton P, Gatherer A. Acute drug-related mortality of people recently released from prisons. Public Health. 2010;124(11):637–639. [PubMed: 20888607]

282.

Gordon MS, Kinlock TW, Schwartz RP, O'Grady KE. A randomized clinical trial of methadone maintenance for prisoners: Findings at 6 months post-release. Addiction. 2008;103(8):1333–1342. [PMC free article: PMC2582162] [PubMed: 18855822]

283.

Wakeman SE, Rich JD. Addiction treatment within U.S. Correctional facilities: Bridging the gap between current practice and evidence-based care. Journal of Addictive Diseases. 2015;34(2-3):220–225. [PubMed: 26076211]

284.

Lee JD, Friedmann PD, Kinlock TW, Nunes EV, Boney TY, Hoskinson RAJ, O'Brien CP. Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. New England Journal of Medicine. 2016;374(13):1232–1242. [PMC free article: PMC5454800] [PubMed: 27028913]

285.

U.S. Department of Justice Office of Justice Programs. Drug courts. 2015. [July 10, 2016]. Retrieved from https://www​.ncjrs.gov​/pdffiles1/nij/238527.pdf.

286.

Bhati AS, Roman JK, Chalfin A. To treat or not to treat: Evidence on the prospects of expanding treatment to drug-involved offenders. Washington, DC: Urban Institute Justice Policy Center; 2008.

287.

Wilson DB, Mitchell O, MacKenzie DL. Drug courts. In: Bruinsma G, Weisburd D, editors. Encyclopedia of Criminology and Criminal Justice. New York, NY: Springer; 2013. pp. 1170–1178.

288.

Sevigny EL, Fuleihan BK, Ferdik FV. Do drug courts reduce the use of incarceration? A meta-analysis. Journal of Criminal Justice. 2013;41(6):416–425.

289.

Wilson DB, Mitchell O, MacKenzie DL. A systematic review of drug court effects on recidivism. Journal of Experimental Criminology. 2006;2(4):459–487.

290.

Gottfredson DC, Najaka SS, Kearley BW, Rocha CM. Long-term effects of participation in the Baltimore City drug treatment court: Results from an experimental study. Journal of Experimental Criminology. 2006;2(1):67–98.

291.

Belenko S, Patapis P, French MT. Economic benefits of drug treatment: A critical review of the evidence for policy makers. 2005. [October 14, 2015]. Retrieved from http://www​.fccmh.org​/resources/docs/EconomicBenefits​_of_Drug_Trx_02.05_.pdf.

292.

Mitchell O, Wilson D, Eggers A, MacKenzie D. Drug courts' effects on criminal offending for juveniles and adults. Campbell Systematic Reviews. 2012;8(4)

293.

Hawken A, Kleiman M. Managing drug involved probationers with swift and certain sanctions: Evaluating Hawaii's HOPE. 2009. [October 12, 2015]. Retrieved from https://www​.ncjrs.gov​/pdfles1/nij/grants/229023.pdf.

294.

Pollack H, Sevigny EL, Reuter P. If drug treatment works so well, why are so many drug users in prison? In: Cook PJ, Ludwig J, McCrary J, editors. Controlling Crime: Strategies and Tradeoffs. Chicago, Illinois: University of Chicago Press; 2011. pp. 125–160.

295.

Kilmer B, Nicosia N, Heaton P, Midgette G. Eficacy of frequent monitoring with swift, certain, and modest sanctions for violations: Insights from South Dakota's 24/7 sobriety project. American Journal of Public Health. 2013;103(1):e37–e43. [PMC free article: PMC3518350] [PubMed: 23153129]

296.

Midgette G, Kilmer B. The effect of Montana's 24/7 sobriety program on DUI re-arrest: Insights from a natural experiment with limited administrative data. Santa Monica, CA: RAND Corporation; 2015.

297.

D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, Fiellin DA. Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA. 2015;313(16):1636–1644. [PMC free article: PMC4527523] [PubMed: 25919527]

298.

Ghitza UE. Overlapping mechanisms of stress-induced relapse to opioid use disorder and chronic pain: Clinical implications. Frontiers in Psychiatry. 2016;7(80) [PMC free article: PMC4852181] [PubMed: 27199787]

299.

Dennis Ml, Titus JC, White MK, Unsicker JI, Hodgkins D. Global appraisal of individual needs Administration guide for the GAIN and related measures. Bloomington, IL: Chestnut Health Systems; 2003.