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Treatment of Patients with Substance Use Disorders Second Edition

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Treatment of Patients with Substance Use Disorders Second Edition PRACTICE GUIDELINE FOR THE Treatment of Patients With Substance Use Disorders Second Edition WORK GROUP ON SUBSTANCE USE DISORDERS Herbert D. Kleber, M.D., Chair Roger D. Weiss, M.D., Vice-Chair Raymond F. Anton Jr., M.D. To n y P. G e o r ge , M .D . Shelly F. Greenfield, M.D., M.P.H. Thomas R. Kosten, M.D. Charles P. O’Brien, M.D., Ph.D. Bruce J. Rounsaville, M.D. Eric C. Strain, M.D. Douglas M. Ziedonis, M.D. Grace Hennessy, M.D. (Consultant) Hilary Smith Connery, M.D., Ph.D. (Consultant) This practice guideline was approved in December 2005 and published in August 2006. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org. 1 Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx. AMERICAN PSYCHIATRIC ASSOCIATION STEERING COMMITTEE ON PRACTICE GUIDELINES John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D. AREA AND COMPONENT LIAISONS Robert Pyles, M.D. (Area I) C. Deborah Cross, M.D. (Area II) Roger Peele, M.D. (Area III) Daniel J. Anzia, M.D. (Area IV) John P. D. Shemo, M.D. (Area V) Lawrence Lurie, M.D. (Area VI) R. Dale Walker, M.D. (Area VII) Mary Ann Barnovitz, M.D. Sheila Hafter Gray, M.D. Sunil Saxena, M.D. Tina Tonnu, M.D. STAFF Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Assistant Project Manager Laura J. Fochtmann, M.D., Medical Editor Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx. CONTENTS Statement of Intent. 5 Guide to Using This Practice Guideline . 6 Development Process . 7 Part A: Treatment Recommendations for Patients With Substance Use Disorders . .9 I. Executive Summary of Recommendations . 9 A. Coding System . 9 B. General Treatment Principles . 9 C. Nicotine Use Disorders: Treatment Principles and Alternatives. 12 D. Alcohol Use Disorders: Treatment Principles and Alternatives . 13 E. Marijuana Use Disorders: Treatment Principles and Alternatives . 13 F. Cocaine Use Disorders: Treatment Principles and Alternatives . 13 G. Opioid Use Disorders: Treatment Principles and Alternatives . 14 II. General Treatment Principles . 15 A. Goals of Treatment . 16 B. Assessment . 18 C. Treatment Settings . 22 D. Psychiatric Management. 28 E. Somatic Treatments . 33 F. Psychosocial Treatments . 36 G. Clinical Features Influencing Treatment . 45 H. Legal and Confidentiality Issues . 70 III. Treatment of Nicotine Dependence . 71 A. Overview . 71 B. Assessment . 72 C. Treatment Settings . 74 D. General Approach to Treatment. 74 E. Somatic Treatments . 80 F. Psychosocial Treatments . 82 G. Treatment of Smokers on Smoke-Free Wards. 83 H. Clinical Features Influencing Treatment . 85 IV. Treatment of Alcohol-Related Disorders . 89 A. Overview . 89 B. Treatment Settings . 90 C. Somatic Treatments . 91 Treatment of Patients With Substance Use Disorders 3 Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx. D. Psychosocial Treatments . 97 E. Clinical Features Influencing Treatment . 100 V. Treatment of Marijuana-Related Disorders . 103 A. Overview . 103 B. Treatment Setting . 103 C. Somatic Treatments. 104 D. Psychosocial Treatments . 104 E. Pregnancy . 104 VI. Treatment of Cocaine-Related Disorders . 105 A. Overview . 105 B. Treatment Settings . 105 C. Somatic Treatments. 106 D. Psychosocial Treatments . 108 E. Clinical Features Influencing Treatment . 109 VII. Treatment of Opioid-Related Disorders. 111 A. Overview . 111 B. Treatment Settings . 112 C. Somatic Treatments. 113 D. Psychosocial Treatments . 120 E. Clinical Features Influencing Treatment . 121 Part B: Background Information and Review of Available Evidence . 124 VIII. Disease Definition, Natural History and Course, and Epidemiology . 124 A. Disease Definition and Diagnostic Features. 124 B. Natural History and Course . 126 C. Epidemiology . 128 IX. Review and Synthesis of Available Evidence . 133 A. Nicotine Dependence. 133 B. Alcohol-Related Disorders . ..
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