Understanding the Primary Goal of Environment of Care in Substance Abuse Treatment

Primary care clinicians play a crucial role in addressing substance abuse and dependence disorders in their patients. Their responsibility extends beyond initial diagnosis and referral; they often become integral members of the treatment team. At minimum, they continue managing patients’ medical needs during specialized treatment, encourage program adherence, and schedule follow-up appointments post-treatment to monitor progress and prevent relapse. Navigating the specialized substance abuse treatment system, however, can be complex. The terminology isn’t standardized, and treatment approaches vary significantly. Describing a facility as inpatient or outpatient only scratches the surface. The system’s nuances differ across regions, with each state and city having unique characteristics. For instance, Minnesota is known for its public and private alcoholism facilities based on the Hazelden and Johnson Institute models, emphasizing Alcoholics Anonymous (AA) and aftercare. California features community-based social model programs rooted in 12-Step, self-help approaches for long-term recovery. In this context, “treatment” refers to formal programs for patients with serious substance use issues unresponsive to brief interventions or office-based strategies. It is also assumed that thorough assessments have been conducted to diagnose and determine the best resources for individual needs.

Directories of Local Substance Abuse Treatment Systems

The initial step in understanding local resources involves gathering information on available substance abuse treatments within the community. Many communities have public or private agencies that compile directories of substance abuse treatment facilities. These directories offer essential details about program services, including type, location, hours, accessibility via public transport, eligibility criteria, costs, staff qualifications, and language proficiencies. These resources may be produced by local health departments, councils on alcoholism and drug abuse, social service organizations, or recovery volunteers. Furthermore, each state has a State-level authority for alcohol and drug issues, often responsible for licensing and program oversight. These authorities frequently publish statewide directories of licensed treatment programs. Another valuable resource is the National Council on Alcohol and Drug Dependence, providing assessments and referrals for a sliding scale fee, alongside free information on national treatment facilities. The Substance Abuse and Mental Health Services Administration (SAMHSA) also distributes a National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs (reachable at 1-800-729-6686).

Familiarity with these resources and key contacts within each facilitates system navigation. Creating a referral tool listing agencies categorized by characteristics, such as services for special populations (women, adolescents, HIV-positive individuals, minorities), is beneficial. Local self-help groups should also be included in resource lists.

Goals and Effectiveness of Treatment

While individual treatment goals vary, all specialized substance abuse programs share three overarching goals (Schuckit, 1994; American Psychiatric Association, 1995):

Reducing substance abuse or achieving abstinence.
Maximizing overall life functioning.
Preventing or lessening relapse frequency and severity.

For most patients, achieving and maintaining abstinence is the Primary Goal Of The Environment Of Care Program (except for methadone-maintained patients). This journey may involve multiple attempts and perceived failures at controlled use before abstinence is fully embraced. Until a patient accepts abstinence, treatment programs focus on minimizing the harms of continued substance use through education, counseling, and self-help groups. These interventions emphasize reducing risky behaviors, building healthy drug-free relationships, changing lifestyle patterns, substituting less risky substances, and decreasing consumption frequency and amount. The ultimate aim is to instill in the patient a sense of personal responsibility for achieving abstinence (American Psychiatric Association, 1995). Complete abstinence is strongly linked to positive long-term outcomes.

However, becoming substance-free is just the beginning. Many individuals entering substance abuse treatment face complex, multifaceted challenges, including co-occurring medical and mental health issues, strained relationships, underdeveloped social and vocational skills, impaired work or school performance, and legal or financial difficulties. These issues may contribute to or result from substance use disorders. Treatment programs must actively assist patients in addressing these problems to facilitate their reintegration into society. This includes improving physical health, treating psychiatric disorders, enhancing psychological well-being, resolving relationship issues, addressing legal and financial problems, and developing necessary educational and vocational skills. Many programs also support spiritual exploration and the discovery of healthy recreational activities.

Increasingly, programs are preparing patients for potential relapse, helping them identify and manage triggers for resumed substance use. Patients learn to recognize cues, manage cravings, develop coping strategies for stressful situations, and have plans for handling slips. Relapse prevention is a critical treatment goal, especially with shorter formal interventions and increased emphasis on aftercare.

While individual treatment effectiveness can be unpredictable, and program success rates vary, evaluations of substance abuse treatment are generally encouraging. Long-term studies consistently show that “treatment works.” Most substance-dependent individuals eventually cease compulsive use and experience less frequent and less severe relapses (American Psychiatric Association, 1995; Landry, 1996). The most significant benefits often occur during active treatment, and sustained abstinence post-treatment is a strong indicator of continued success. Approximately 90 percent of those abstinent for two years remain substance-free at the 10-year mark (American Psychiatric Association, 1995). Longer treatment durations, particularly episodes of three months or more, are also associated with better outcomes (Gerstein and Harwood, 1990). Individuals with lower levels of pre-existing psychopathology and fewer social, vocational, and legal problems tend to benefit most from treatment. Continued participation in aftercare or self-help groups post-treatment also correlates with positive outcomes (American Psychiatric Association, 1995).

Numerous randomized clinical trials and outcome studies have examined the effectiveness of various alcohol and drug abuse treatments. While a detailed review is beyond this scope, key findings from an Institute of Medicine report on alcohol studies are relevant:

No single treatment is universally effective for all individuals with alcohol problems, and inpatient treatment holds no overall advantage over outpatient care.
Addressing co-occurring life problems improves treatment outcomes.
Therapist and patient characteristics, treatment processes, post-treatment factors, and their interactions influence outcomes.
Reducing alcohol consumption or achieving abstinence generally leads to improvements in other life areas (Institute of Medicine, 1990).

A comparison of treatment compliance and relapse rates for individuals treated for opiate, cocaine, and nicotine dependence with those for chronic medical conditions like hypertension, asthma, and diabetes revealed similar response rates across both categories (National Institute on Drug Abuse, 1996). All these conditions necessitate behavioral change and medication adherence for successful management. This comparison suggests that drug addiction treatment has comparable success rates to treatments for other chronic medical illnesses (National Institute on Drug Abuse, 1996).

Treatment Dimensions

The terminology used to describe substance use disorder treatment has evolved alongside the development of specialized systems and adaptations to healthcare and financing changes. Language differences persist between public and private programs, and to some extent, between treatments initially designed for alcohol versus illicit drug problems. Programs are increasingly focused on individualizing care, tailoring programs to patients rather than adhering to fixed, standardized formats with set lengths of stay or service sequences.

A SAMHSA publication, Overview of Addiction Treatment Effectiveness (Landry, 1996), categorizes substance abuse treatment across three dimensions: (1) treatment approach, encompassing the philosophical principles guiding care, admission and discharge policies, outcome expectations, attitudes towards patient behavior, and staff types; (2) treatment setting, referring to the physical environment of care delivery; and (3) treatment components, denoting specific clinical interventions and services tailored to individual needs. These components can vary in duration and intensity. Treatment stage also represents a crucial dimension, as different resources may be targeted at various recovery phases. Programs are also designed for special populations based on age, gender, race/ethnicity, primary substance, and functional level or medical condition, aiming to provide the most appropriate environment and services.

Treatment Models and Approaches

Historically, treatment programs were shaped by the philosophical beliefs of their founders regarding the causes of alcoholism and drug dependence. While most programs now integrate elements from all three, understanding these historical distinctions helps clinicians recognize the underlying influences in different programs. The three historical orientations underpinning treatment models are:

Medical Model: Emphasizes biological, genetic, or physiological causes of addiction requiring physician-led treatment, often involving pharmacotherapy to manage symptoms or modify behavior (e.g., disulfiram, methadone, withdrawal management).
Psychological Model: Focuses on maladaptive learning, motivational issues, or emotional dysfunction as primary drivers of substance abuse. This approach uses psychotherapy or behavioral therapy led by mental health professionals.
Sociocultural Model: Highlights social and cultural environment deficiencies or socialization processes that can be improved by modifying the environment, particularly through self-help groups, spiritual practices, and supportive social networks. Recovery expertise is often valued, with authority residing in individuals with lived experience.

These models have largely converged into a biopsychosocial approach in contemporary programs. Currently, four major treatment approaches are common in public and private programs:

Treatment Settings

Substance abuse treatment primarily occurs in two settings: inpatient and outpatient. Despite significant cost differences, research hasn’t strongly linked treatment setting to outcome success. In fact, there isn’t a clear correlation between setting and service types, although service provision does correlate with post-treatment outcomes. Generally, most patients can benefit from either inpatient or outpatient settings, though certain subgroups may respond better to specific environments (Landry, 1996).

Initially, matching patient needs to the appropriate setting is crucial. The goal is to place patients in the least restrictive yet safe and effective environment, progressing along a continuum of care as they demonstrate cooperation and reduced need for highly structured settings or specialized services (like medical or nursing supervision, room, and board). However, progression isn’t always linear towards less intensive care; relapse or lack of response in one setting may necessitate moving to a more restrictive environment (American Psychiatric Association, 1995; Landry, 1996).

The continuum of treatment settings, from most to least intensive, includes inpatient hospitalization, residential treatment, intensive outpatient treatment, and outpatient treatment.

Inpatient hospitalization provides 24/7 treatment and supervision by a multidisciplinary team, focusing on medical management of detoxification or acute medical and psychiatric crises, typically for short durations. Hospital care is now usually reserved for patients with: (1) severe overdoses and respiratory depression or coma; (2) severe withdrawal syndromes complicated by multiple substances or delirium tremens history; (3) acute or chronic medical conditions complicating withdrawal; (4) significant psychiatric comorbidity posing danger to self or others; and (5) acute substance dependence unresponsive to less intensive treatments (American Psychiatric Association, 1995).

Residential treatment in a 24-hour supervised live-in facility is suited for patients with significant substance use problems lacking sufficient motivation or social support for abstinence but not meeting hospitalization criteria. Many residential facilities offer medical detox monitoring and are appropriate for those needing this level of care without requiring management of other medical or psychiatric issues. These facilities vary in intensity and duration, ranging from long-term therapeutic communities to less supervised halfway and quarterway houses for community reintegration. Specialized residential programs cater to adolescents, pregnant/postpartum women and children, criminal justice system referrals, or public inebriates with histories of treatment failure (American Psychiatric Association, 1995; Landry, 1996).

Intensive outpatient treatment (IOT) requires at least 9 weekly hours, often in 3-8 hour daily increments, 5-7 days a week. Sometimes called partial hospitalization, IOT is often recommended for early treatment stages or transitions from residential/hospital settings. It suits patients needing more structure than standard outpatient care but not full-time supervision, with some existing support systems. IOT includes day care, evening, and weekend programs offering comprehensive services. Session frequency and length are usually reduced as patients progress, show decreased relapse risk, and build community supports (American Psychiatric Association, 1995).

Outpatient treatment, the least intensive setting, involves less than 9 weekly hours, typically with once or twice-weekly individual, group, or family counseling and other services. Programs range from ambulatory methadone maintenance to drug-free approaches. Outpatient participants need adequate support systems, living arrangements, transportation, and motivation for consistent attendance and benefit from less intensive efforts. Outpatient care is used by public programs and private practitioners for initial interventions, extended aftercare, and follow-up (Institute of Medicine, 1990).

Treatment Techniques

Within each treatment approach, various specialized techniques (modalities, components, services) are used to achieve specific goals. Patients usually receive multiple services in combination throughout treatment. The emphasis may shift from initial pharmacologic interventions for withdrawal to behavioral therapy, self-help, and relapse prevention during primary care and stabilization, and ongoing AA participation post-treatment. Methadone maintenance patients receive pharmacotherapy throughout all care phases, alongside other psychological, social, or legal services as needed. Categorization of these techniques is not standardized, and terminology varies. However, principal elements include:

Pharmacotherapies: To discourage substance use, manage withdrawal, block euphoric effects or cravings, replace illicit drugs with prescriptions, or treat co-occurring psychiatric issues (see Appendix A for details).
Psychosocial or psychological interventions: To modify destructive feelings, attitudes, and behaviors via individual, group, marital, or family therapy.
Behavioral therapies: To reduce undesirable behaviors and encourage positive ones.
Self-help groups: For mutual support and encouragement for achieving and maintaining abstinence, pre-, during, and post-formal treatment.

Pharmacotherapy

Medications to manage withdrawal use cross-tolerance to substitute the abused drug with a safer drug in the same class, which is then gradually tapered. Benzodiazepines are common for alcohol withdrawal, and methadone for opioid withdrawal, with buprenorphine and clonidine also used. Cocaine withdrawal medication efficacy is less established, though drugs like buprenorphine, amantadine, and desipramine have been tried. Acute opioid intoxication with respiratory depression or coma requires immediate naloxone reversal. However, in opioid-dependent individuals, naloxone can precipitate withdrawal (American Psychiatric Association, 1995; Institute of Medicine, 1990; Gerstein and Harwood, 1990). (See Appendix A.)

Medications to discourage substance use induce unpleasant reactions or diminish euphoric effects. Disulfiram (Antabuse) inhibits alcohol metabolism, causing toxic acetaldehyde buildup and unpleasant side effects like flushing, nausea, and hypotension. Naltrexone, an opioid antagonist, reduces alcohol relapse by blocking the effects of the first drink and is used with motivated, opioid-free individuals to block heroin/morphine effects. These agents (disulfiram, naltrexone) are adjuncts to broader treatment, particularly for relapse prevention motivation (American Psychiatric Association, 1995; Landry, 1996). (See Appendix A.)

Agonist substitution therapy replaces an illicit drug with a prescribed medication. Opioid maintenance treatment, the primary example, prevents withdrawal and reduces cravings in opioid-dependent patients. Methadone and longer-acting levo-alpha-acetyl-methadol (LAAM) are leading therapies. LAAM is taken three times weekly, methadone daily. Buprenorphine, a mixed agonist-antagonist, also suppresses withdrawal, reduces craving, and blocks euphoric effects (American Psychiatric Association, 1995; Landry, 1996).

Medications to treat comorbid psychiatric conditions are essential for patients with co-occurring substance use and psychiatric disorders. Prescribing requires caution due to diagnostic complexity and overdose risks, especially when combined with substances of abuse. Co-morbidity is prevalent in substance dependence. Pharmacotherapy is often indicated (e.g., lithium for bipolar disorder, neuroleptics for schizophrenia, antidepressants for depression). Psychiatric diagnoses should ideally be made after detoxification and 3-4 weeks of substance-free observation, as withdrawal symptoms can mimic psychiatric disorders. Primary care clinicians and substance abuse programs should avoid prescribing medications for insomnia, anxiety, or depression (especially benzodiazepines) without confirmed psychiatric diagnoses in patients with substance use disorders. Even with confirmed diagnoses, medications should have low overdose lethality, minimal interaction with abused substances, and low abuse potential. SSRIs for depression and buspirone for anxiety are examples. Prescriptions should be limited and closely monitored (Institute of Medicine, 1990; Schuckit, 1994; American Psychiatric Association, 1995; Landry, 1996).

For dually diagnosed patients, a conservative, sequential approach is recommended. For anxiety and alcohol dependence, non-psychoactive methods like exercise, biofeedback, or stress reduction should be tried first. If ineffective, non-psychoactive drugs like buspirone (or SSRIs for depression) are next. Psychoactive medications should be considered only if other approaches fail. Proper prescribing for these patients follows the “six Ds” (Landry et al., 1991a):

Diagnosis: Essential, confirmed by history, examination, and tests before prescribing psychotropics. Assess substance use in anxiety disorders, and vice-versa, rather than just treating presenting symptoms.
Dosage: Appropriate for diagnosis and severity, avoiding over- or undermedication. High doses may need office administration to ensure compliance.
Duration: Limit to package insert or Physician’s Desk Reference recommendations to prevent dependence.
Discontinuation: Consider for complications (toxicity, dependence), at trial expiration, crisis resolution, or when alternative coping strategies are learned.
Dependence Development: Continuously monitor. Warn patients about this risk and the need to decide if the condition justifies dependence.
Documentation: Critical, including presenting complaints, diagnosis, treatment course, prescriptions (filled or refused), consultations, and recommendations.

Psychosocial Interventions

Individual therapy uses psychodynamic principles, modified with limit-setting and advice, to address interpersonal functioning issues. Supportive-expressive therapy, tested for cocaine and alcohol dependence, creates a safe therapeutic alliance to address negative relationship patterns (American Psychiatric Association, 1995; National Institute on Drug Abuse, unpublished). It focuses on current life problems, not developmental issues, and is often used with comprehensive treatment. Research suggests individual psychotherapy is most beneficial for opiate-dependent patients with moderate psychopathology who can form therapeutic alliances (National Institute on Drug Abuse, unpublished). Drug counseling by paraprofessionals focuses on drug use reduction strategies and pragmatic treatment-related issues (e.g., urine test results, attendance, referrals), differing from psychotherapy by mental health professionals (American Psychiatric Association, 1995).

Group therapy is frequently used during primary and extended substance abuse treatment. Approaches vary widely in session length, frequency, group size, enrollment type (open/closed), duration, therapist number and training, and interaction style. The balance between confrontation and support is often debated.

Group therapy offers closeness, shared experiences, emotional communication, and mutual support in overcoming substance abuse. Group dynamics principles extend beyond therapy to educational presentations and discussions about substances, their effects, HIV/STI prevention, and other related topics (Institute of Medicine, 1990; American Psychiatric Association, 1995).

Marital therapy and family therapy address substance abuse behaviors and maladaptive family interaction and communication patterns. Various family therapy schools (structural, strategic, behavioral, psychodynamic) are used. Goals, timing within treatment, and family types (nuclear, married couples, multigenerational, remarried, same-sex couples, etc.) vary. Family intervention, a structured attempt to engage resistant individuals in treatment, can motivate program entry. Family involvement aids medication compliance, attendance, and treatment planning, while therapy focused on family dynamics and communication can create a more supportive recovery environment. Research supports behavioral relationship therapy’s effectiveness in improving family functioning and treatment outcomes (Landry, 1996; Institute of Medicine, 1990; American Psychiatric Association, 1995). Multidimensional Family Therapy (MFT) for parents and substance-abusing adolescents shows promise in improving parenting skills and adolescent abstinence up to a year post-intervention (National Institute on Drug Abuse, 1996).

Behavioral Therapies

Cognitive behavioral therapy (CBT) aims to change cognitive processes leading to maladaptive behavior, intervene in substance abuse event chains, and reinforce skills for achieving and maintaining abstinence. CBT techniques consistently improve self-control and social skills, reducing drinking (American Psychiatric Association, 1995). Strategies include self-monitoring, goal setting, rewards, and coping skill development. Stress management training (biofeedback, relaxation, meditation, exercise) is popular in substance abuse treatment. Social skills training to improve communication and interpersonal interactions is also effective in promoting sobriety and reducing relapse, focusing on expressing feelings, handling criticism, and initiating social encounters (Institute of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Behavioral contracting or contingency management uses pre-defined rewards and punishments, agreed upon by therapist and patient (and others), to reinforce desired behaviors. Effective use requires meaningful contingencies, mutual contract development, and consistent application. Positive contingencies may be more effective than negative ones (National Institute on Drug Abuse, unpublished). Negative contingencies should be ethical and not counterproductive (e.g., reducing methadone for continued illicit drug use). Contingency management is effective within a comprehensive treatment program (National Institute on Drug Abuse, unpublished; Institute of Medicine, 1990; Landry, 1996).

Relapse prevention helps patients identify high-risk situations or emotional triggers for substance abuse and learn substitute coping responses to cravings. Patients develop strategies for managing external stressors and learn to view lapses as part of recovery, interrupting them before severe consequences. Relapse prevention is as effective as other psychosocial treatments, especially for patients with sociopathy or psychiatric symptoms (American Psychiatric Association, 1995). Cognitive-behavioral strategies, self-efficacy improvement, self-control training, and cue exposure are components. Relapse prevention is now a vital part of most treatment, learned during intensive stages and practiced in aftercare (Institute of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Self-Help Groups

Mutual support, 12-Step groups like Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, and alternatives (Rational Recovery, Women for Sobriety) are fundamental to many treatments and continuing care. While AA’s effectiveness hasn’t been rigorously evaluated, these fellowships help individuals change behavior patterns, manage cravings, and maintain hope for abstinence. Self-help groups also facilitate new social networks, drug-free activities, healthy relationships, and avoidance of stressful situations.

The 12-step process, guided by a sponsor, encourages reassessing past experiences and taking responsibility for substance use disorders. Attendance frequency varies, with more intensive involvement available as needed.

Patients averse to AA’s spiritual focus and abstinence orientation may benefit from Rational Recovery or Recovery Training and Self-Help (RTSH) programs. Patients on psychotropic medications or methadone/LAAM should attend groups accepting pharmacotherapy. Younger individuals, people of color, and LGBTQ+ individuals often find more acceptance in groups with similar members. Al-Anon, Alateen, Nar-Anon, and similar groups support friends and family of those in recovery or those who refuse treatment, offering education about substance use disorders and teaching how to curb enabling behaviors. Frequent attendance, having a sponsor, working the 12 steps, and leading meetings are associated with improved substance-abusing behavior among participants (National Institute on Drug Abuse, 1993; American Psychiatric Association, 1995; Landry, 1996).

Other Primary and Ancillary Services

Patients in treatment may also need social services, vocational training, education, legal aid, financial counseling, health/dental care, and mental health treatment. These may be onsite or via referrals. Adjunctive services to encourage treatment entry and retention include childcare, transportation, financial aid, supported housing, and other support. Additional service types depend on the population served. For example, individuals who inject heroin, cocaine, or methamphetamine need specialized HIV/AIDS education, identification, counseling, and healthcare services, less relevant for alcohol dependence programs.

The Treatment Process

All treatment components, approaches, techniques, and settings require monitoring and adjustment as treatment progresses. Primary care clinicians should understand these aspects of appropriate care:

Repeating assessments: To evaluate changing medical, psychological, social, vocational, educational, and recreational needs, especially as acute issues resolve and new problems emerge. Homelessness or withdrawal needs initial attention before family issues, for example. Suicidal thoughts require immediate attention.
Developing a comprehensive treatment plan: Clearly outlining identified problems, explicit goals and strategies, and specified techniques and services provided by designated specialists with frequencies and intensities.
Monitoring progress and clinical status: Through written notes or reports detailing treatment responses and service outcomes (counseling, group meetings, urine tests, physical exams, medications, referrals). Each patient needs a confidential individual treatment record.
Establishing a therapeutic alliance: With an empathetic primary therapist or counselor who builds patient and family trust and ensures care continuity. Crucial in early treatment to prevent dropout and encourage participation.
Providing education: To help patients and designated others understand the diagnosis, etiology, prognosis, and treatment benefits and risks. Informed consent for potentially risky procedures is always necessary (American Psychiatric Association, 1995).

Treatment Programs for Special Populations

Various substance abuse treatment programs are designed for specific populations, including women, pregnant/postpartum mothers, adolescents, elderly individuals, minorities, public inebriates/homeless individuals, drinking drivers, and children of alcoholics. These programs exist in public and private sectors, using residential and ambulatory settings with therapeutic community, Minnesota model, outpatient drug-free, and methadone maintenance approaches. Research hasn’t confirmed these specialized programs are superior in outcomes to mainstream efforts, and their cost-effectiveness and applicability to diverse groups are questioned. Clinicians should avoid defining patients solely by age, gender, race, or function, as other factors (addiction severity, employment, criminal involvement, education, socioeconomic status) may be more impactful on outcomes. However, clinical observations suggest that considering and addressing special population needs can enhance treatment. Key components of special population programs include (Institute of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Women are more prone to comorbid depression and anxiety, including PTSD from abuse. Historically, substance use patterns differed from men (prescription drugs), but are now converging. Treatment for women addresses childcare needs, parenting skills, healthy relationships, preventing exploitation/violence, HIV/STI prevention, and enhancing self-esteem. Higher female staff ratios and same-sex groups may improve retention.

Pregnant and postpartum women and their children have unique needs: prenatal/obstetrical care, pediatric care, child development knowledge, parenting skills, economic security, and safe housing. Women of childbearing age need birth control information and awareness of substance use risks during pregnancy (abortion, placental abruption, preeclampsia, premature labor, birth defects, fetal growth impairment, low birth weight, stillbirth, neonatal withdrawal). Methadone maintenance during pregnancy and postpartum is often preferred for opioid-dependent women with unstable lifestyles unlikely to remain abstinent. However, some addiction medications (disulfiram, naltrexone) are contraindicated in pregnancy. See Appendix A and TIP 2, Pregnant, Substance-Using Women (CSAT, 1993a).

Adolescents require developmentally appropriate, peer-focused treatment. Educational needs, family involvement in planning and therapy for dysfunction are crucial. Adolescent substance abuse often co-occurs with depression, eating disorders, and sexual abuse history (American Psychiatric Association, 1995). Family history of substance abuse predicts adolescent involvement. See TIP 4, Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents (CSAT, 1993c).

Elderly persons may have undiagnosed/undertreated substance dependence on alcohol or prescribed benzodiazepines/sedative-hypnotics, contributing to falls, confusion, and overdose, as aging reduces medication metabolism. Co-existing medical/psychiatric conditions complicate treatment and compliance.

Minority group members may identify with cultural norms and institutions enhancing social acceptance. While initial abstinence-focused treatment stages may not be affected by minority status, developing drug-free social supports and lifestyles during extended treatment and aftercare can be enhanced by culturally similar support groups. For African Americans, church involvement and spiritual elements may improve outcomes. Native American programs often incorporate traditions. Bilingual staff and materials are vital for Hispanic programs. However, cultural sensitivity may be less critical for individuals less strongly identified with ethnic/cultural groups, with socioeconomic differences potentially being more relevant to treatment retention.

Confidentiality

Federal regulations (42 C.F.R. Part 2) mandate confidentiality for patient information regarding substance use or abuse to encourage treatment entry without fear of stigma or discrimination from unauthorized disclosure. 1987 amendments clarified that general medical settings and hospital records are not covered unless the unit’s primary focus is substance abuse treatment (CSAT, 1995b, p. 64). However, discretion is always advised when handling records containing substance use disorder information.

Patient written consent is required for information disclosure or redisclosure revealing patient identity when referring for substance abuse assessment or specialized treatment, except in medical emergencies or suspected child abuse reporting. Treatment programs often seek to coordinate care with primary care providers, essential for certain patients like pregnant women with substance use disorders. See Appendix B for detailed confidentiality discussion and TIPs 4, 8, 11, 13, 16, and 19 for further context.

The Role of the Primary Care Clinician Throughout Treatment

Primary care clinicians are vital in identifying, screening, and referring patients with substance use disorders for assessment/treatment, and in providing brief interventions for milder problems. They can also offer ongoing support to patients in formal treatment by:

Learning about community treatment resources.
Staying informed about the patient’s specific treatment program, its approach, and services.
Requesting periodic formal reports on treatment plans and progress (with patient permission).
Clarifying their role in continued patient care (medical conditions, prescriptions, compliance monitoring).
Reinforcing the importance of continued treatment to patients and families.

Completing treatment is just the start of recovery. Primary care clinicians should inquire about the treated problem at every visit, monitoring relapse potential and taking preventive steps (Brown, 1992).

For patients who refuse referral or drop out, primary care clinicians should:

Continue treating medical problems, including substance-related issues.
Reiterate the substance use disorder diagnosis and remain ready to refer for specialized treatment, seeking acceptable alternatives if initial referrals are refused.
Encourage family participation in Al-Anon, Alateen, Adult Children of Alcoholics, or similar groups for education on substance use disorders, distress minimization, and avoiding enabling behaviors.
Exercise caution in prescribing psychotropic medications for anxiety, insomnia, etc., as these can worsen substance abuse.