Substance use disorders involve alcohol and a range of other legal and illicit drugs, and are characterised by a preoccupation with or craving for the substance, a greater priority to substance use than other goals, and/or a difficulty controlling consumption. Use of the substance may continue despite negative impacts on other activities, roles, relationships, and physical and mental health. Increased physical tolerance to the substance and withdrawal symptoms may also occur.
Broad impacts on social and cognitive functioning and on physical and mental health emerge with increasing problem severity. Diffuse cognitive impairment may persist for up to 12 months post-detoxification in alcohol dependence. Psychological comorbidity is common, particularly mood and anxiety disorders.
A quarter of all Australians will have a substance use disorder in their lifetime. One in five will consume alcohol at a level that puts them at risk of harm from an alcohol-related disease or injury over their lifetime. Australians aged 18 to 29 years are at higher risk than other age groups.
General principles of psychological assessment
A comprehensive assessment is critical to effective intervention. Valid retrospective self-reports of substance use over 1 to 3 months can be obtained with event-cued recall (‘Timeline Followback’, see Sobell & Sobell, 1992), provided disclosure is seen as safe. Self report under these conditions can even be superior to biomedical markers. Accurate reports of alcohol consumption require awareness of the volume consumed and ethanol content (10g ethanol = one standard drink), and reports of illegal drug use are affected by unknown and variable levels of active constituents. Consumption of tobacco and cannabis may be best estimated by the frequency and amount of purchases, together with days of use.
The use of self-monitoring for assessment has reactive effects and is therefore best suited to short periodic assessments to identify risk situations. The use of phone apps and web programs allows cueing, date stamping and graphical feedback.
Recommended screening instruments include the Alcohol Use Disorders Identification Test and the Drug Abuse Screening Test. Dependence measures include the Severity of Alcohol Dependence Questionnaire, Severity of Opiate Dependence Questionnaire, and Severity of Dependence Scales (amphetamine, cannabis, benzodiazepines). Estimates of drug and alcohol use that generalise from the last three occasions are provided by the Opiate Treatment Index.
Evidence-based psychological treatment guidance
- Psychoeducation involves assessing consumption as well as substance-related behaviour, and providing normative feedback and information on the impact of use. However, simply providing information about harms is ineffective as a sole intervention, and confrontation has nil or negative effects.
- Brief behavioural interventions (typically 1-2 sessions) that provide advice and elicit planning for change result in small to moderate average improvements, especially in men and people with low to moderate physical dependence, and where assessments and intervention are administered repeatedly.
- Motivational interviewing, which aims to enhance motivation for change by exploring and resolving ambivalence about reducing substance use, may give better results than other brief interventions.
- Cognitive behavioural therapy (CBT) typically applies learning-based approaches to modify maladaptive behavioural and cognitive patterns, and increases confidence for change through development of coping skills.
- Twelve-step approaches (e.g., Alcoholics Anonymous), which emphasise shared experiences and mutual support as central to addiction recovery, may support sustained change, but adding other therapies produces increased benefit.
- Additional adjunctive approaches include contingency management to assist session attendance and reduce consumption while contingencies are in place. Effects on their withdrawal depend on the acquisition of skills and engagement of alternative incentives.
- Social skills training, community reinforcement and behavioural relationship therapy have research support, but may not add to effects of brief interventions in people with low-severity problems. Repeated cue exposure in the clinic can have positive effects, but does not add to the impact of other cognitive behavioural therapies.
Large scale studies demonstrate equivalent efficacy of motivational interviewing, CBT and 12-step approaches to alcohol use disorder treatment. These treatments are often delivered in combination (especially motivational interviewing and CBT).
People with severe physical dependence on alcohol and multiple treatment failures are generally indicated for abstinence rather than controlled drinking.
Note that rapid reductions in substance use can provoke physical withdrawal. Use of higher doses of central nervous system depressants (e.g., alcohol, benzodiazepines) may particularly require medical supervision of withdrawal due to risk of severe complications.
Emerging treatment directions for the future
New pharmacotherapies are expected to emerge over coming years, as are advances in behavioural epigenetics. A targeted combination of psychological therapies in combination with pharmacotherapies or in populations with specific genetic risk may provide a significant advance. Emerging research on imagery-based techniques to elicit and maintain motivation is showing promising early results, as are treatments to address impulsivity associated with substance abuse.
Key reading and information sources
- ‘Substance use disorders’ chapter (Kavanagh, Connor & Young, 2010) in Handbook of clinical psychology competencies (Thomas & Hersen, Eds.)
- Guidelines for the treatment of alcohol problems (Haber et al., 2009)
- Management of cannabis use disorder: A clinician’s guide (Copeland, Frewen & Elkins, 2006)
- Methamphetamine dependence and treatment (Lee et al., 2007)