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Integrating pharmacotherapy with treatment planning for alcohol dependence

July 1, 2007
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A well-conceived treatment plan includes statements that encapsulate the patient's identified problems, goals, and objectives, as well as the interventions to be used in treatment, the time frames, and the staff responsible for treatment. The patient's problems must be clearly identified, precisely described, and prioritized by severity or risk. These statements should use specific language and not be just a diagnosis, such as “alcohol dependence with bipolar disorder.” For example, statements that precisely describe a patient's inability to comprehend the destructiveness of his disease might read, “The patient acknowledges his performance at work is suffering but does not recognize or may be unwilling to admit to how his drinking may be a contributing factor.” This detailed description is more useful than “the patient denies a problem with alcohol” and allows the patient and clinician to develop more focused discussions—such as regarding alcohol's effects on productivity—and create specific goals to address alcohol-related difficulties. The six dimensions described by the ASAM PPC-2R can be used to organize and prioritize the specific problems and challenges faced by the patient.

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

Including medications in planning

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

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

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

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