ASHA Glossary: Treatment Strategy. Examples of treatment strategy: habilitative/ rehabilitative techniques include exercises and movements designed to change . Individuals seeking help for stimulant dependence receive the majority of their treatment in outpatient treatment programs. Accordingly, the treatment strategies . Eur Urol. Nov;74(5) doi: /yaniq.xyz Epub Jul Treatment Strategy for Newly Diagnosed T1 High-grade Bladder.
In this article, we will review not only the different trial designs for biomarker-driven studies with their respective advantages and opportunities but also the potential pitfalls that led to the design of the EORTC protocol. We will also discuss the scientific and logistic challenges of this trial.
Master protocols include two different study designs: One of the advantages of this histology agnostic approach is to investigate the activity of targeted drugs across different cancer types, even in rare cancers for which clinical trials do not exist.
They also offer the possibility to target low incidence molecular alterations. Selected histology agnostic biomarker-driven approaches. A histology-specific approach is interesting to avoid the heterogeneity due to different biology across various tumor types. Selected histology specific biomarker-driven approaches. These screening initiatives can be histology-agnostic or histology-specific.
Different diagnostic tests are routinely used to predict the activity or resistance of some targeted therapies. Most of them are evaluated on tumor biopsies, although liquid biopsies are entering into the clinic [e.
Biomarkers can be evaluated not only at the proteomic level such as the estrogen receptor status assessed by immunohistochemistry IHC but also at the genomic level such as Human Epidermal Receptor-2 HER2 amplifications or EGFR activating mutations. Most of them use DNA sequencing on tumor biopsies.
Reproducibility and reliability of the molecular screening tools are important. Most of the trials use certified laboratories, but the analysis is not always centralized.
In these cases, some trials carried out an interlaboratory analytical validation before starting the trial [ 24 ] or validated the assay [ 25 ]. A fresh biopsy is probably more reliable than an archival one. Indeed, the cancer molecular profile can change during disease evolution [ 26 ]. However, the number of patients who were finally treated with a matched targeted therapy was low: Different reasons may explain these low enrolment rate: A way to partially solve these issues is to include the access to drugs into the clinical trial design.
The number of treated patients is higher in these two last trials due to a preplanned access to matched targeted therapies. In addition, for the Battle trial, the molecular profile strategy was disease-specific and adapted to NSCLC, explaining the high prevalence of some of the investigated biomarkers. Treatment selection based on DNA biomarkers has proved its efficiency: Pembrolizumab has been approved, independently of the tumor type, for microsatellite instability-high and mismatch repair deficient cancers [ 32 ] as well as for the first-line treatment of metastatic NSCLC with high PD-L1 expression [ 33 ].
Different end points are used in biomarker-driven trials. The approach is judged efficient if it modifies the natural history of the disease and is associated with a longer PFS than the previous line of treatment. In IMPACT, the clinical outcomes of patients with molecular aberrations treated with matched therapy were compared with those of consecutive patients who were not treated with a matched therapy.
The use of nonoptimal targeted drugs or suboptimal dosages in phase I trials, and sometimes the level of evidence concerning the investigated biomarker s may explain the limited treatment efficacy observed. In the SUMMIT trial [ 35 ], a basket trial studying neratinib in patients with a tumor harboring either HER2 or HER 3 mutations, the primary end point was reached only for breast cancer, and not for lung, bladder, and colorectal cancers, underlining the importance of the histology and the tissue of cancer origin.
The SHIVA trial was the first randomized trial comparing a molecularly targeted therapy based on tumor molecular profiling versus conventional therapy for advanced cancer [ 17 ]. This study tested the overall strategy of a biomarker-driven treatment approach versus standard therapy. The trial did not meet its primary end point PFS. Several reasons could explain this overall negative result.
First, they used drugs that were marketed in France at that time and not necessarily the best in class to target the molecular alteration identified. Second, the experimental arm was also heterogeneous with multiple drugs and various tumor types.
This could have blinded the benefit of some drugs in some specific cancer s. To avoid a negative trial linked with inadequate target modulation by the selected agents, all the targeted agents used in NCI-MPACT have been validated to engage their purported targets and have at least an established phase II dose. However, these trials offer only one potential therapeutic option for the very low percentage of patients harboring these rare genomic events. This results in a high rate of screening failure.
Ongoing biomarker-driven trials in squamous cell carcinoma of the head and neck. Targetable genomic alterations in HPV-negative SCCHN include events in genes related to kinase growth factor family receptors or their downstream molecular pathways: Below, we describe the overall study design as well as the different treatment cohorts.
Each patient must undergo a fresh tumor biopsy. NGS is carried out to identify somatic mutations and copy number alterations with a custom panel that has been designed for the trial.
This panel covers 13 oncogenes and tumor suppressor genes: Based on the molecular alterations identified, each patient is allocated to one of the cohorts. The full protocol includes a core protocol and several addenda. For each experimental treatment, there is one separate addendum that contains the confidential information related to the drug. The national health regulatory authorities, the ethical committee, and the investigators have access to the core protocol and all the addenda.
Sample sizes vary from 32 to 76 patients across cohorts. The study can be amended to add other cohorts based on drug availabilities or other biomarker hypotheses. However, afatinib does not increase OS. Biomarkers analyses were carried out within this trial [ 36 ]. Partial responses were also observed in some patients with squamous cell lung cancer, SCCHN, and adenoid cystic carcinoma [ 48 ]. We will investigate palbociclib in patients with p16 negative tumors harboring CCND1 amplification.
Therefore, other immunotherapy approaches have to be investigated. HLA-E is a nonclassical major histocompatibility complex molecule that constitutes a way for cancer cells to escape immune surveillance.
In the first immunotherapy cohort, patients will receive monalizumab monotherapy. The trial is open for inclusion since December Because many stimulant-dependent clients engage in binge use, a comparable goal is to achieve a period of abstinence approximately twice as long as the usual time period between binges.
Brief, frequent counseling sessions can reinforce the short-term goal of immediate abstinence and establish a therapeutic alliance between the client and counselor. Events of the past 24 hours are reviewed in each session, and recommendations are provided for navigating the next 24 hours. Establishing a social support system and conducting frequent and regular urine testing are also critical to providing structure, support, and accountability.
The daily scheduling exercise described in the previous section continues to be an extremely important organizing strategy through this phase of treatment. Proactively planning time is a direct counterpoint to the impulsive, free-form lifestyle of the substance user. Clients should write down their schedules during session time, and session time should be used to review compliance with the schedule prepared in the previous session.
Many clients will find this task difficult and may resist this "regimentation" of their time. However, if counselors reinforce successive efforts to follow such schedules, compliance will improve. Stimulant-dependent clients in outpatient programs need structure that provides support for engaging in healthy behaviors. Urine testing is part of that structure. It should not be presented or used primarily as an investigative tool or as a method to test the honesty of clients.
Rather, it should be used and presented as a means of support for initiating and maintaining sobriety. Urine testing should be conducted for the primary stimulant and for secondary substances. Testing should be conducted in concert with the clinic visits. During this phase of treatment, urine testing should be conducted no less than once a week.
Tests should be spaced so that the results are obtained from a previous test before conducting the next test, which generally means spacing tests no more frequently than every 3 days. Testing should be randomly conducted, although it is advisable to test on days that closely follow periods of high risk, such as holidays, paydays, and weekends.
To ensure that the urine is a valid sample from the client, testing should be either observed or monitored through the use of temperature strips. Most stimulant-dependent clients also use some other substance, such as alcohol or marijuana. They often do not perceive their use of a secondary substance as problematic. Indeed, for many clients, their secondary substance use may not have been associated with adverse consequences or compulsive use. As a result, such clients need help to identify the connections between the use of other substances and their stimulant addiction.
Clients should learn that using another substance increases the likelihood of relapse to stimulants Rawson et al. Clients should learn that some secondary substances of choice, such as alcohol, can have a disinhibiting effect and lead rapidly to stimulant use Higgins et al.
A similar finding has anecdotally been reported by MA users with regard to their use of marijuana Rawson et al. Clients should learn that the dose or the frequency of use of the secondary substance is not important, but that disinhibiting effects and potent conditioned responses and cues can occur at low doses.
Achieving abstinence helps clients learn to develop substance-free coping mechanisms. Clients can be helped to examine some of the reasons for why they use secondary substances. For example, some stimulant-dependent women use alcohol as a way to tolerate an abusive situation.
Also, clients can be taught avoidance strategies for the secondary substance, such as eschewing high-risk situations where alcohol will be served. Clients are sometimes ready for treatment for the primary substance of choice but not their secondary substance. Thus, secondary substance use is common during this phase of treatment. Although programs should promote abstinence from all psychoactive drugs, clients who use their secondary substance should not be discontinued from treatment solely because of this use.
Rather, they should receive treatment strategies to help them decrease the likelihood of doing so in the future. Contingency management described in Chapter 3 reinforces desired behavior by providing immediate consequences.
It can be used to improve compliance with treatment components and to promote abstinence. It sets concrete goals and emphasizes positive behavior changes. In contingency management, a specific target behavior, such as providing stimulant-free urine samples, is selected. The target behavior should be easily measured. Next, a specific and desirable contingency is identified and selected as a reward for each time that the target behavior is accomplished.
The reward should not be exchangeable for cash, but can have a cash equivalent, such as a cash-equivalent voucher system or nonrefundable movie passes. The link between the targeted behavior and the reward should be specified. Finally, the agreement should be documented in a written contract and should specify the duration and any changes over time in contingencies. Contingency management interventions have been shown in controlled research studies to be effective for helping cocaine users to achieve and sustain abstinence Higgins et al.
The process of identifying cues and triggers is dynamic and ongoing and will change over time. For example, as clients learn more about the associations between specific emotional states and stimulant cues, they can become increasingly sophisticated about identifying and avoiding or defusing potential triggers.
However, there are several strategies that should be used very early in the treatment process to help clients to avoid certain external or environmental cues that are likely to be potent triggers for stimulant cravings and urges Washton, These include discarding drugs, drug paraphernalia, and materials related to substance use; breaking contact with dealers and users; avoiding high-risk places; and developing basic refusal skills.
First, if the client has not already done so, a specific action plan must be developed to find and get rid of all substances including alcohol and drug-related paraphernalia. Clients should be encouraged to accomplish this task with the help of a family member, sober friend, or Step sponsor to ensure that all drug-related items are found and permanently discarded.
In addition to objects used to prepare or inject stimulants, materials associated with drug use that should be discarded include phone numbers of dealers and prostitutes, pornographic videotapes, containers used to hold drug supplies, mirrors or special tables used to cut stimulants, and weighing scales.
Second, it is essential for clients to develop specific action plans to break contacts with dealers and other stimulant users. When spouses and significant others are themselves stimulant users, it is important to develop a plan to assertively encourage the significant other to also seek help.
Third, an action plan should be developed to help the client avoid high-risk places. This involves identifying places strongly associated with stimulant use and making specific plans to avoid them.
This may include taking different routes home from work, going to certain locations at times different than normal, or using a "buddy system" when going to a high-risk area. Finally, a plan of action should be developed to deal with confrontations with acquaintances who are still using stimulants. Clients should prepare specific drug-refusal statements that can be used when they encounter drug-using friends and practice with their counselor and fellow group members.
This action plan must include immediately leaving the situation after the encounter. Client Worksheet 5, Action Plan for Avoidance Strategies see Appendix B , can be used to assist clients develop strategies to avoid potent high-risk cues and triggers.
Clients with stimulant use disorders often do not understand many of the things that they have experienced as a result of their stimulant use, such as impulsive behaviors, anger and hostility, and cognitive deficits.
They require education to help them understand the learning and conditioning factors associated with stimulant use. Similarly, they need information about the impact of stimulants and other substances on the brain and behavior, such as cognitive impairment and forgetfulness. Information about stimulant-induced behavior can help them understand the episodes of anger, hostility, and sexual compulsivity.
Clients, especially those with MA use disorders, should be educated about the early abstinence syndrome and protracted abstinence. Also, they should learn how their secondary substance of choice has an important role in relation to relapse to stimulant use.
They require education about the biopsychosocial processes of addiction, treatment, and recovery. They should also learn about the stages of treatment and recovery, as well as the specific tasks, goals, and pitfalls of each. Although many clients with stimulant use disorders in early treatment phases have poor retention of information and temporary cognitive deficits, they can understand basic information about cues and triggers.
They can be taught how conditioning factors can elicit drug cravings and urges, that these cravings and urges are a natural part of early abstinence, and that there are methods to deal with them. Clients with stimulant use disorders should be provided with basic education about the conditioning process and how this process is applied to their disorder. These educational efforts should describe basic conditioning factors related to stimulant use as described in Figure Basic Conditioning Factors in Stimulant Use.
Stimulant cravings are the predictable results of chronic stimulant use and typically continue long after the stimulant use is stopped.
Stimulant and secondary substance use becomes strongly associated with certain people, places, objects, activities, behaviors, and feelings.
Because clients with stimulant use disorders may have engaged in stimulant use hundreds or thousands of times, their daily life is filled with numerous reminders or cues that can trigger stimulant cravings and stimulant use. Although it is common for many clients to have some of the same cues and reminders, such as seeing the drug or the dealer, there are wide differences among clients regarding the specific type, strength, and number of cues.
Accordingly, it is important for counselors to help clients to acknowledge and identify the cluster of cues unique to their lives. The primary tasks here are to teach clients how cues are developed and how these cues can trigger drug craving and use, and to encourage them to actively identify their cues and triggers. This can be accomplished through exercises and worksheets. External and internal cues often pervade every aspect of stimulant users' lives. As a result, clients should develop action plans with specific behavioral and mental steps to prevent cues from becoming triggers.
They should be taught to avoid, wherever possible, external cues that strongly remind them of stimulant use. They should be taught to leave situations that are making them think about stimulants or experience cravings. They should be taught specific techniques to stop drug thoughts from becoming drug cravings.
Finally, they should be taught immediately achievable techniques that can defuse stimulant cravings from leading to drug use. Client Worksheet 4, Action Plan for Cues and Triggers, can be a valuable part of such educational efforts. Families and significant others should be encouraged to participate in treatment. The family should receive education about the addictive process, its role in the process, and its role in the treatment and recovery processes.
Family members also need information about the effects of stimulants on the brain and behavior in order to understand the stimulant-induced behavior.
They should receive a primer on the classical conditioning aspects of stimulant use disorders, and look at cravings as a conditioned response. The information should be clear and simple, and not too conceptual or abstract. The ideal format is a group psychoeducational session, consisting of a brief didactic session, followed by a video and a group discussion. The process should help to elicit discussions and examples about how what they heard and saw applies to them.
Also, family participation can be an opportunity to do an informal evaluation of the substance use disorders of other family members. Through this process, program staff members may be able to identify certain treatment needs, which may require treatment or referral. For clients who are actively working on achieving abstinence and who have a stable marriage or relationship with someone who is not using stimulants, involving the spouse and client in couples or relationship counseling can be valuable.
This strategy can help to improve communication skills and the relationship. Research has shown that marital and relationship counseling can have positive effects on substance treatment Landry, ; Stanton and Shadish, If relationship counseling is considered, the significant other must not have problems with substance use excepting nicotine , and the significant other must agree with the basic treatment goals of abstinence and be willing to engage in behaviors that support sobriety.
Some research results related to behavioral relationship therapy are presented in Figure A review of research evidence regarding behavioral relationship therapy and substance use disorder treatment outcomes Landry, noted that Behavioral relationship therapy more Clients with stimulant use disorders, especially during the early phases of abstinence, seem to have low frustration tolerance and appear to be restless in group sessions.
But as soon as clients are able to do so generally within a few days , they should be introduced to a structured and therapeutic group process, such as a beginner's recovery group. These groups can provide a preexisting support network and a forum for openly talking about early abstinence problems. Clients can be given the short-term goal of attending ninety Step meetings in 90 days. Also, clients can be encouraged to establish or reestablish relationships with nonsubstance-using friends and family and, perhaps, to establish a "buddy system" with a healthy family member, friend, or Step sponsor to call during crises.
Some clients with stimulant use disorders develop significant stimulant-induced compulsive sexual behaviors. These can include compulsive masturbation, compulsive or impulsive sex with prostitutes, and compulsive pornographic viewing. For these clients, interventions can be conducted, the result of which is to decrease the likelihood of both the compulsive sexual behaviors and stimulant relapse.
A first step involves asking clients to agree to a temporary sex abstinence plan for 2 to 4 weeks. Next, clients should be made aware that sexual feelings, thoughts, and fantasies are conceptualized as very high-risk triggers that will be acted out if they are not talked out.
For people who have this problem, even normal, routine sexual thoughts and contacts can quickly become major triggers. Programs should provide a safe environment for such clients to talk about these issues, either within the context of a group session or individual counseling.
Discussions should be held about safe and unsafe sexual behaviors in regard to relapse prevention. Specific and clear recommendations should include not having sex with anyone with whom the client has gotten high, and not pursuing sex with anonymous or unknown partners. Client fears should be addressed, such as the fear that sex without drugs will be boring or impossible. Many of the avoidance strategies used with psychoactive substances can be employed for these clients in relation to sexual cues.
For some clients, the sexual behavior has a higher reinforcing effect than the stimulant. Clients will need reminders to stay away from people, places, and things related to sexual behaviors. These can include porno shops, certain streets with prostitutes, and video shops. Also, clients should be educated about reciprocal relapse, in which one compulsive behavior is inextricably involved with another, and therefore, engaging in the behaviors associated with one condition can cause one to act out behaviors associated with the other condition.
It is rare for clients to go from active, full-blown stimulant addiction to complete abstinence. Rather, most clients go through a phase during which there are days without substance use and occasional days with substance use. In fact, substance use during this early transition from abusive or dependent use to abstinence should not be considered relapse because there was not a genuine period of abstinence from which to relapse.
Thus, substance use during this period of transition should not be characterized as relapse but rather as difficulty in breaking the pattern of stimulant use. Also, clients should understand that substance use is normal during this difficult phase, despite their hard efforts to the contrary. Program staff members should understand that substance use during this phase is not a sign of poor motivation but reflects multiple processes, including cues and triggers and a not-yet-stable brain.
Slips can also be thought of as a behavioral indicator of conflict and ambivalence about stopping. At the same time, counselors should clearly communicate that they are not giving clients permission to use. Rather, they are making efforts to keep the client engaged in treatment. Early slips should be considered opportunities for adjusting the treatment plan and trying other strategies.
They can be opportunities for gaining an appreciation of the strength of cravings and triggers, and learning new methods to handle them. Some recommendations for guiding group discussions of slips are listed in Figure Responding to Slips in Group Sessions. Ask the person to provide a detailed account of the sequence of feelings, events, and circumstances that led to the slip. Encourage group members to ask the person more Early slips should not be considered as tragic failures but rather as mistakes.
When slips occur, counselors can make a verbal or behavioral contract with clients regarding short-term achievable goals.
This can include such simple tasks as agreeing not to use psychoactive substances for the next 24 hours, to attend a specific number of clinic sessions over the next couple of days, and to bring a significant other to treatment the next day. This process can involve having the client identify areas that need to be addressed or enhanced. It may be important to take a closer look at cues and triggers and determine if anything has changed.
Many stimulant users can discontinue the use of cocaine or MA for periods of time without the assistance of treatment involvement. As previously mentioned, "withdrawal" is a less important consideration for stimulant users than it is for users of substances that produce a physically uncomfortable withdrawal, such as opiates, alcohol, and benzodiazepines.
For stimulant users, the trick is not in stopping, but in staying off, or avoiding relapse. In the treatment of stimulant users, achieving abstinence is the "warm-up act"; sustaining abstinence is "the main event. The dichotomy between strategies to achieve abstinence and strategies to maintain abstinence is somewhat artificial and arbitrary because many of the same principles apply and many of the same techniques are used over the course of treatment.
However, there are some issues that appear to increase in importance over the 1- to 4-month period typically needed for learning how to maintain abstinence. These are discussed below. Once stimulant use is discontinued and a client's sleeping and eating habits are normalized, the majority of symptoms described as the "crash" typically lessens.
However, the resolution of the crash symptoms does not signal that the brain is back to normal. Clinical observations show that there are significant biological and psychological symptoms that continue to hamper the functioning of stimulant users 90 to days after discontinuation of substance use. The symptoms described include a mild dysphoria, difficulty concentrating, anhedonia, lack of energy, short-term memory disturbance, and irritability.
The existence of these "protracted withdrawal" symptoms has been the subject of some debate. Recently, evidence from positron emission tomography PET scan research has provided tangible evidence in monkeys that MA use produces very significant changes in brain functioning that last for more than 6 months Melega, a.
The brain areas involved and the neurochemical deficits observed in these PET scans are consistent with the clinical symptomatology of this "protracted withdrawal syndrome.
There are a number of common patterns to the relapse episodes of stimulant users who are attempting to maintain abstinence Havassy et al. Several studies have reported on the relationship between alcohol use and cocaine relapse, and other reports have supported this same pattern with alcohol and marijuana for MA relapse Rawson, ; Carroll et al.
Return to substance-using friends. The Panel's clinical experience suggests that returning to substance-using friends is a primary reason for a stimulant user's relapse.
Sexual behavior associated with substance use. Particularly for men, sexual behaviors especially associated with stimulant use e. Craving elicited by external and internal stimuli. The powerful influence of Pavlovian conditioned cues on the production of craving has been reported by many stimulant users as a contributor to stimulant relapse O'Brien et al.
Emotional states can be important antecedents to relapse Havassy et al. Stimulant users find anger, depression, loneliness, frustration, and boredom quite difficult to manage, and these feelings can initiate a behavioral sequence that ends in stimulant use.
Many stimulant users have spent a good portion of the years leading up to treatment entry with their lives revolving around substance use. Frequently, during the initial 6 to 12 months of abstinence they have little idea what to do with their lives. In particular, they often have very poor social and recreational behavior repertoires.
The creation of new, positively reinforcing activities and interests is an important part of this period of treatment. The strategies recommended for maintaining abstinence draw primarily from the behavioral and cognitive-behavioral models described in Chapter 3. One overall theme in the following materials is that newly abstinent stimulant users can be taught a set of information and skills that can help them avoid relapse. The following strategies have been found to help stimulant users maintain their abstinence.
The purpose of functional analysis is to teach clients how to understand their stimulant use so that they can engage in problem-solving solutions that will reduce the probability of future stimulant use.
The core components of a functional analysis are 1 teaching clients to examine the types of circumstances, situations, thoughts, and feelings that increase the likelihood that they will use stimulants; 2 counseling clients to examine the positive, immediate, but short-term consequences of their stimulant use; and 3 encouraging clients to review the negative and often delayed consequences of their stimulant use.
Client Worksheet 29, Components of a Functional Analysis, gives clients an overview of these components. Employing contingency management agreements can help sustain initial treatment gains. When contingency management is used, the behavioral contract must be based on objective criteria such as urinalysis results and attendance at group therapy sessions.
All specifics must be clearly detailed in the written contract. Systematic and consistent implementation of the agreement is crucial: Reinforcement must be delivered promptly when the contract is satisfied and withheld when it is not. Frequent, positive reinforcement of success is critical. Client Worksheet 28, Sample Behavioral Contract for Stimulant Abstinence, can be modified and used to help meet the treatment needs of specific clients.
As this sample contract illustrates, contingency management can involve receiving "points," credits, money, or other benefits or incentives. Relapse prevention techniques teach clients to recognize high-risk situations for substance use, to implement coping strategies when confronted with high-risk events, and to apply strategies to prevent a full-blown relapse should an episode of substance use occur Marlatt and Gordon, The techniques involve several cognitive-behavioral interventions that focus on skills training, cognitive reframing, and lifestyle modification.
Relapse prevention techniques fall into several categories: As reviewed in the previous chapter, there is a substantial body of literature on the use of relapse prevention techniques with stimulant users. The manual developed by Kathleen Carroll provides an excellent set of relapse prevention exercises, which can be directly applied in treatment settings Carroll, The Matrix manual Rawson et al. Washton has published a set of relapse prevention materials that can be easily incorporated into treatment programming Washton, a , b.
Also, Figure sets out basic precepts to be used in addressing relapse. The following treatment themes are critical to the relapse prevention-based treatment strategies.
An integral aspect of relapse prevention involves eliminating and correcting dangerous myths and misconceptions regarding the process of relapse and the appropriate treatment response to it. The Consensus Panel more One major element of a relapse prevention approach is the delivery of information to stimulant users about a variety of use-related topics.
One frequently used format for delivering this information is in psychoeducation groups. These groups consist of a mixture of education, peer support, and recovery-oriented therapy.
The group leader provides a brief discussion or shows a short videotape on a specific topic that is relevant to the group participants.
The group members are encouraged to discuss the topic as it is personally relevant to them. Also, the group leader encourages group members to discuss the problems, challenges, and successes that they are currently experiencing. The topics typically discussed in a psychoeducation group for clients with stimulant use disorders include Cravings and conditioning Protracted abstinence Stimulants and the brain Identification of high-risk situations Developing coping and stress management skills Enhancing self-efficacy in dealing with relapse-risky situations Counteracting euphoria and the desire to test control over use Developing a balanced lifestyle Responding safely to slips to avoid escalation Establishing behavioral accountability.
Many of these are addressed in the sections below. Some recommendations for running a relapse prevention group are presented in Figure Recommendations for Running a Relapse Prevention Group.
A relapse prevention group is a forum for clients to create a program of recovery and relapse prevention. The group provides a setting for sharing more During the previous phase of establishing abstinence, clients should have learned skills for negotiating high-risk situations. In particular, clients should be able to identify cues and triggers, develop action plans for cues and triggers, and deal with early abstinence symptoms. Once clients learn to identify, manage, and avoid high-risk situations, the counselor and client should try to determine if the client is confident in her ability to use those skills in the real world.
It is important to evaluate and have clients engage in self-evaluation to determine if they are overconfident regarding their avoidance and refusal skills, and to determine if they actually have more skills than they imagine. Client Worksheet 11, Evaluating Your Self-Efficacy Regarding Relapse, can help clients to evaluate how they think they would handle certain high-risk situations that they cannot avoid.
Similarly, Client Worksheet 12, Increasing Your Self-Efficacy, involves role-playing exercises designed to simulate real-world high-risk situations and to increase the client's self-efficacy.
Two important risk factors for stimulant relapse are euphoric recall and the desire to test control over stimulant use. Euphoric recall is the act of remembering only the pleasures associated with stimulant use and not the adverse consequences. Euphoric recall is a potent relapse risk factor because it minimizes clients' perceptions of stimulants' danger, promoting an ambivalence about quitting.
For these reasons, so-called "war stories" that include euphoric recall and selective memory are powerful relapse triggers and should be strongly discouraged in recovery groups. After beginning to feel healthier, more in control of their lives, and free of some of their stimulant-related problems, some clients feel that they are ready to try a new approach to stimulant use.
For example, some may feel that if they are "careful," they can use stimulants without losing control over their use. Others may feel that this is a good time to try using stimulants "one last time," just to see if they can do it without escalating into compulsive use and loss of control. Clients should be taught that urges to test their control over stimulant use are a powerful relapse warning sign.
Client Worksheet 19, Fantasies About Controlled Use, can be part of psychoeducation efforts designed to recognize these fantasies as warning signs that need to be addressed. Also, Client Worksheet 20, Those Ugly Reminders, can help clients make lists of negative consequences of stimulant use, which can be reviewed when they experience cravings, fantasize about controlled use, or romanticize their experiences with stimulants. Stimulant slips and relapses are mistakes, not failures, and indicate a need to adjust the treatment plan.
After a slip, a relapse-specific session should be scheduled as rapidly as possible. The counselor should reassure clients that he has not given up on them.
Counselors and clients together review and analyze the events leading up to the slip and identify which warning signs were present.
Clients should be encouraged to consider the events of the previous few weeks, such as changes at work, at school, in social networks, or in family situations. Find out more about cookies.
I am proud of the successes achieved over this period, driven by Alcohol and Drug Partnerships, our nationally-commissioned organisations, Health Boards, Councils, Integration Authorities, Third Sector Organisations, Mutual Aid Organisations, but also, crucially, by individuals, their families and wider communities.
A key success to improving outcomes for individuals, families and communities has been the introduction of minimum unit pricing for alcohol, the establishment of recovery oriented systems of care, and the growth of over recovery communities throughout Scotland.
We have also provided a vision that recovery is possible, recognising that each recovery journey is unique. But we also recognise that through an increasing visibility of recovery, we can begin to tackle some of the issues of stigma and discrimination that affect so many individuals and family members. Despite our other successes, over the last five years we have, tragically, seen a sharp increase in drug related deaths across Scotland. Everyone has the right to health and to live free from the harms of alcohol and drugs.
Everyone has the right to be treated with respect and dignity and for their individual recovery journey to be fully supported. This strategy is, therefore, about how we best support people across alcohol and drug issues - taking a human rights-based, public health approach to ensure we are delivering the best possible care, treatment and responses for individuals and communities. There is a growing awareness that those experiencing problematic alcohol and drug use are often carrying other burdens such as poverty, inequality and health challenges.
This means they need to be supported rather than be stigmatised. Treatment services and organisations in Scotland are already jointly tackling the harms caused by alcohol and drugs and this new strategy reflects that - bringing together our approach to tackling the problematic use of alcohol and drugs for the first time.
Rethinking osteoporosis: long-term treatment strategy and sequential therapy
J Clin Psychiatry. ;68 Suppl Treatment strategies to prevent relapse and encourage remission. Kane JM(1). Author information: (1) Department of. Tailoring the colorectal cancer disease assessment to the treatment strategy The treatment options for metastatic colorectal cancer (CRC) continue to evolve. The scenario of multiple sclerosis (MS) treatment has changed profoundly in recent decades. In this setting, one of two strategies is usually.