**4. Treatment approaches**

**3.5. Diagnosis of the substance-related disorders**

152 Recent Advances in Drug Addiction Research and Clinical Applications

dromes are not included.

substance use

substance use

the following are the eleven possible symptoms:

**3.** Spending a lot of time obtaining the substance

**4.** Craving or a strong desire to use the substance

made worse by substance use

**2.** Wanting to cut down or quit but not being able to do it

**8.** Recurrent use of substance in physically hazardous situations

The history of psychology and psychiatry includes a legacy of efforts to develop the most elegant and powerful nosology of disorders of psychological adaptation. There is evidence of attempts to categorize disorders as far back as the ancients, but increased focus emerged around 1900 and has accelerated since. The first comprehensive modern work was the Diagnostic and Statistical Manual (DSM) in 1952 [32]. Given that psychoanalysis still en‐ joyed hegemony in the clinical world of the late 1940s, the original DSM was relatively brief and grounded in clinical lore and psychoanalytic theory. The DSM subsequently evolved from a primarily psychoanalytic work to an atheoretical compendium that is designed to reflect the highest levels of clinical and empirical science. By the time of DSM-II (1968 [33]), the role of theory was substantially reduced and increasing specificity in diagnostic criteria was realized.

The introduction of the Diagnostic and Statistical Manual of Mental Disorders (Fifth edition: DSM-V [34]) brought revisions to previous diagnostic criteria in the DSM tradition. Most recently, the DSM-IV [35] used two main categories of substance misuse conditions, sub‐ stance abuse and substance dependence. The DSM-IV criteria were considered to be inade‐ quately descriptive of what was seen clinically, and the new criteria are claimed to be a substantial improvement. These two categories from DSM-IV were combined into one disorder in DSM-V that is diagnosed in conjunction with a rating from mild to severe. This also eliminates the "substance dependence" category, which was widely seen as easily confused with "addiction." While using the same underlying criteria, each substance is indicated as a distinct use disorder, including alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics or anxiolytics, stimulants, and tobacco. Caffeine-related syn‐

It is important to review the DSM-V criteria for substance use disorder. It is important to bear in mind that each of these eleven criteria may be manifest in different ways and will be influenced heavily by the pharmacology of the specific substance. For each of the substances,

**5.** Repeatedly unable to carry out major obligations at work, school, or home due to

**6.** Continued use despite persistent or recurring social or interpersonal problems caused or

**7.** Stopping or reducing important social, occupational, or recreational activities due to

**1.** Taking the substance in larger amounts and for longer than intended

There have been a staggering number of treatment approaches substance-related problems over the centuries [17]. It is virtually impossible to organize and categorize all treatment approaches, and the intersection of treatment method and type of professional further complicates the picture. The difficulties of professional domains and perspectives are further exacerbated by the relative lack of evidence for the effectiveness for different interventions [36]. In fact, there is some evidence to suggest that the specific treatment approach or techni‐ que is not as important to outcome as are factors associated with intervention relationships such as empathy [37]. Garner [38] issued a clear call for greater methodological rigor in studies of treatment efficacy to ensure development of treatment approaches that are grounded in empirical support. Recent suggestions have begun to clarify how this research might be conducted. DuPont et al. [39] suggested that addiction should be considered separate from other forms of health care because of the complexity and need for better kinds of research. In addition, they highlighted the high level of investment required in successful treatment, the variety of substances associated with disorders, and the varieties of organizational struc‐ tures present in the treatment community. They also highlighted the severity, complexity, and chronicity of these disorders as important guideposts for the development of outcome measures. In light of the complexity of the treatment factors just noted, the final section of this chapter will highlight a few of the major treatment perspectives.

#### **4.1. Detoxification**

The critical role of detoxification in substance abuse treatment has continued since its central place in nineteenth century treatment. Because of a relative lack of knowledge about the exact

impact of substance use, addictive processes, and treatment, there was obvious emphasis detoxification as an essential step in recovery. In addition, there was considerable emphasis on physical dependence as a central element of addiction. So, work with a patient began with simply clearing the body of the toxic substances, often with inpatient medical supervision and sometimes medications such as benzodiazepines. Today, detoxification is not technically considered to be actual treatment for a substance use disorder, though it is widely seen as a fundamental first step for treatment. However, contemporary perspectives on treatment manifest great variability in the rate of movement from detoxification to longer forms of intervention. The relative merits of gradual versus sudden withdrawal quickly became a matter of intense dispute in the medical community [1,42–44]. Modern research has identi‐ fied factors that make detoxification a more effective part of a treatment system in which approximately one-fifth of annual admissions include detoxification [40]. The availability of intervention beyond detoxification is greatly influenced by healthcare economics. Despite efforts associated with the Affordable Care Act, many persons with substance use disorders are uninsured or underinsured. It is clear that finances are associated with the quality of intervention as well as limitations on the quantity and nature of service modalities. The Wellstone and Domenici move in 2008 to bring parity to mental health care did attempt to reduce barriers to treatment utilization, reduce financial burdens, and decrease stigma, though the success of those efforts is a matter of debate [41].

#### **4.2. Harm reduction**

"Harm reduction" is a relatively recent approach that functions in contrast to abstinence-only models. There have been several major contributors who have influenced this approach, though their assumptions and strategies are similar (in particular [1, 42–44]. With a pragmat‐ ic perspective that is theoretically inclusive, the harm reduction approach considers psycho‐ active substance use to be a part of the human experience and works to minimize damage resulting from use. The harm reduction approach, like many other approaches, considers substance use (and misuse) to be a complex result of many forces and maintains the view that there are constructive and destructive ways to use many substances. Without minimizing the real destruction from use, this perspective emphasizes the participation of substance users in reducing harm as well as the great significance of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities as vulnerability factors. With this broad emphasis, intervention is associated with the unique realities of the person who is struggling with substances and predetermined treatments are not embraced. Proponents of harm reduction thus characterize it as a public health alternative to moral, criminal, or disease models. From this point of view, it is appropriate to adopt a "whatever it takes" perspective on intervention with persons who abuse substances.

Peele, in particular, supports harm reduction and speaks in contrast to the AA tradition, promoting natural solutions in the context of careful goal-setting and the making of person‐ al meaning in recovery. His writing includes specific arguments about the perils of the disease model. Peele argues that addicts are not different from other people in respects other than the addiction. In addition, Peele disputes a number of long-standing assumptions of the AA

tradition. He does not agree that recovery depends on forces outside the individual or that substance abusers are unable to control themselves in any situation. Since Jellenik's seminal contributions to the disease model, "addiction" has been perceived as a predictable, progres‐ sive, and fatal disease. Peele argues that this is not the standard progression through which an addict must inexorably pass, and recovery does not consist of a lifelong conscription to absence and twelve-step methods. In fact, Peele argues that the pessimism and determinism that are intrinsic to the disease model actually contribute to the likelihood of relapse and continued harm.

Some harm reduction techniques include methadone maintenance, which serves as a safer alternative to heroin use because of the longer half-life of methadone and the safer route of administration. Other approaches may include over the counter medications or even care in maintaining hydration with club drugs [45]. Needle exchange programs have been a highly visible and controversial approach to harm reduction that targets the high levels of risk associated with sharing intravenous drug administration supplies [46].

The harm reduction approach has been bolstered by the addition of mindfulness techniques [47]. Grounded in Buddhist tradition, mindfulness is considered to be the cultivation of awareness in the present moment. Mindfulness practices have been integrated into many of the therapeutic approaches since it began to appear in Western teachings in the 1950s. Mindfulness began to appear into the scientific literature associated with substance abuse treatment relatively recently [48].

#### **4.3. Relapse prevention**

impact of substance use, addictive processes, and treatment, there was obvious emphasis detoxification as an essential step in recovery. In addition, there was considerable emphasis on physical dependence as a central element of addiction. So, work with a patient began with simply clearing the body of the toxic substances, often with inpatient medical supervision and sometimes medications such as benzodiazepines. Today, detoxification is not technically considered to be actual treatment for a substance use disorder, though it is widely seen as a fundamental first step for treatment. However, contemporary perspectives on treatment manifest great variability in the rate of movement from detoxification to longer forms of intervention. The relative merits of gradual versus sudden withdrawal quickly became a matter of intense dispute in the medical community [1,42–44]. Modern research has identi‐ fied factors that make detoxification a more effective part of a treatment system in which approximately one-fifth of annual admissions include detoxification [40]. The availability of intervention beyond detoxification is greatly influenced by healthcare economics. Despite efforts associated with the Affordable Care Act, many persons with substance use disorders are uninsured or underinsured. It is clear that finances are associated with the quality of intervention as well as limitations on the quantity and nature of service modalities. The Wellstone and Domenici move in 2008 to bring parity to mental health care did attempt to reduce barriers to treatment utilization, reduce financial burdens, and decrease stigma, though

"Harm reduction" is a relatively recent approach that functions in contrast to abstinence-only models. There have been several major contributors who have influenced this approach, though their assumptions and strategies are similar (in particular [1, 42–44]. With a pragmat‐ ic perspective that is theoretically inclusive, the harm reduction approach considers psycho‐ active substance use to be a part of the human experience and works to minimize damage resulting from use. The harm reduction approach, like many other approaches, considers substance use (and misuse) to be a complex result of many forces and maintains the view that there are constructive and destructive ways to use many substances. Without minimizing the real destruction from use, this perspective emphasizes the participation of substance users in reducing harm as well as the great significance of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities as vulnerability factors. With this broad emphasis, intervention is associated with the unique realities of the person who is struggling with substances and predetermined treatments are not embraced. Proponents of harm reduction thus characterize it as a public health alternative to moral, criminal, or disease models. From this point of view, it is appropriate to adopt a "whatever it takes" perspective

Peele, in particular, supports harm reduction and speaks in contrast to the AA tradition, promoting natural solutions in the context of careful goal-setting and the making of person‐ al meaning in recovery. His writing includes specific arguments about the perils of the disease model. Peele argues that addicts are not different from other people in respects other than the addiction. In addition, Peele disputes a number of long-standing assumptions of the AA

the success of those efforts is a matter of debate [41].

154 Recent Advances in Drug Addiction Research and Clinical Applications

on intervention with persons who abuse substances.

**4.2. Harm reduction**

"Relapse" refers to a return of problem behavior following an interval during which an individual has been relatively problem free. The study of relapse has been motivated by the prevalence of relapse, by attempts to bolster treatment effectiveness as well as to understand the persistence of substance-related problems. The practice of relapse prevention is an eclectic blend of a variety of approaches that have mixed empirical support. Many of these ap‐ proaches are rooted in clinician beliefs and experience as well as guidance from recovering users. For example, "booster sessions" may follow the termination of regular treatment contact. Relapse prevention strategies are likely to be a part of a final phase of treatment and at‐ tempts to solidify relapse prevention may be a routine protocol during a termination phase. Recovering users are called upon to identify high risk situations and develop a range of robust coping mechanisms. Similar to this evaluation of the environment, persons in the treatment are encouraged to identify warning signs within him or herself as well as overall factors of vulnerability that may increase the risk of relapse. Attempts to generalize training experien‐ ces that are cultivated in treatment include exercises to bring lessons from treatment to reallife situations.

#### **4.4. Interpersonal therapies**

Since the inception of psychoanalysis in the late 1800s, the *relationship* between a would-be healer and a suffering person has been considered to be critical to the success of interven‐ tions. As the understanding of the fundamental conditions of therapeutic relationships advanced in the twentieth century, so did empirical support for the essential quality of certain therapeutic conditions. Interpersonal therapies were not initially designed for substance abusing persons, and the psychopharmacology of substances was recognized early in the history of psychotherapy as a complicating factor in treatment. Freud's exaltation of and subsequent struggle with cocaine is a well-known example of this uncomfortable reality. Early psychoanalytic theories of substance misuse were provocative and controversial [49–52]. In general, however, themes emerged that suggested that substance use problems developed in association with the person's inability to meet their inner needs in more adaptive ways [53].

Interpersonal approaches to substance use disorders are optimized when recognizing and incorporating psychopharmacological and substance use realities. In addition to the realities of substance misuse, patients are encouraged to confront issues that emerge in the absence of the substances. For example, a recovering user may be encouraged to grieve the "lost friend" of the substance. Shame is frequently identified and challenged as a factor in the inevitable frustration of needs. Defense mechanisms, originally couched in psychoanalytic language as negative factors, became seen as essential elements of psychic life and forces which need to be improved and not eliminated. For persons who use substances in problematic ways, defense mechanisms are identified as adaptive or maladaptive and modified accordingly. In general, the enhancement of self-expression and the relative satisfaction associated with human connections are bolstered in this approach.

#### **4.5. Cognitive behavior therapy**

Cognitive behavior therapy (CBT) may reasonably consider one of the dominant perspec‐ tives in mental health and substance abuse therapeutics today [54]. CBT is a blend of behav‐ ior therapy (BT) and cognitive therapy (CT). BT was originally introduced as an attempt to apply laboratory-based behaviorism to human change processes. BT was, in part, a reaction to psychoanalysis that was seen as pessimistic, deterministic, and nearly impossible to investigate empirically. An example of a behavioral approach to substance abuse therapeu‐ tics is contingency management (CM[55, 56]). CM uses the principles of operant condition‐ ing and provides established reinforcers for drug abstinence or other objective measures of drug abstinence. The rewards may be a coupon for goods and services, a verbal reward, or small monetary tokens. This approach includes escalating rewards with rules for resetting the reward when there has been a relapse. Another example of a behavioral approach illustrates the role of contingencies on task participation (in contrast to abstinence as in the previous example). Spohr et al. [57] reported the results of behavioral approach in which rewards were established related to participation in probation and treatment of tasks.

Cognitive therapy has a broad history, in as much as there is evidence of some of the central tenets of the approach in the writings of the ancients [54]. While there are an increasing number of variants, cognitive therapy addresses thinking patterns that contribute to problems in adaptation.

Another approach that some consider to be within the cognitive behavioral tradition is dialectical behavior therapy (DBT [58]). DBT is an empirically supported therapy approach that was designed originally to assist persons who are struggling with symptoms of border‐ line personality disorder. Since its original development, it has been adapted for the treat‐ ment of substance use disorders [59]. DBT prioritizes risky behaviors (self-injury) and then works directly with substance use issues. Next, the approach attends to effects of substance use, such as legal jeopardy and vocational difficulties. Finally, DBT builds skills for broad psychological adaptation and relapse prevention.

#### **4.6. Contributions from contemporary pharmacology and neuroscience**

tions. As the understanding of the fundamental conditions of therapeutic relationships advanced in the twentieth century, so did empirical support for the essential quality of certain therapeutic conditions. Interpersonal therapies were not initially designed for substance abusing persons, and the psychopharmacology of substances was recognized early in the history of psychotherapy as a complicating factor in treatment. Freud's exaltation of and subsequent struggle with cocaine is a well-known example of this uncomfortable reality. Early psychoanalytic theories of substance misuse were provocative and controversial [49–52]. In general, however, themes emerged that suggested that substance use problems developed in association with the person's inability to meet their inner needs in more adaptive ways [53]. Interpersonal approaches to substance use disorders are optimized when recognizing and incorporating psychopharmacological and substance use realities. In addition to the realities of substance misuse, patients are encouraged to confront issues that emerge in the absence of the substances. For example, a recovering user may be encouraged to grieve the "lost friend" of the substance. Shame is frequently identified and challenged as a factor in the inevitable frustration of needs. Defense mechanisms, originally couched in psychoanalytic language as negative factors, became seen as essential elements of psychic life and forces which need to be improved and not eliminated. For persons who use substances in problematic ways, defense mechanisms are identified as adaptive or maladaptive and modified accordingly. In general, the enhancement of self-expression and the relative satisfaction associated with human

Cognitive behavior therapy (CBT) may reasonably consider one of the dominant perspec‐ tives in mental health and substance abuse therapeutics today [54]. CBT is a blend of behav‐ ior therapy (BT) and cognitive therapy (CT). BT was originally introduced as an attempt to apply laboratory-based behaviorism to human change processes. BT was, in part, a reaction to psychoanalysis that was seen as pessimistic, deterministic, and nearly impossible to investigate empirically. An example of a behavioral approach to substance abuse therapeu‐ tics is contingency management (CM[55, 56]). CM uses the principles of operant condition‐ ing and provides established reinforcers for drug abstinence or other objective measures of drug abstinence. The rewards may be a coupon for goods and services, a verbal reward, or small monetary tokens. This approach includes escalating rewards with rules for resetting the reward when there has been a relapse. Another example of a behavioral approach illustrates the role of contingencies on task participation (in contrast to abstinence as in the previous example). Spohr et al. [57] reported the results of behavioral approach in which rewards were

Cognitive therapy has a broad history, in as much as there is evidence of some of the central tenets of the approach in the writings of the ancients [54]. While there are an increasing number of variants, cognitive therapy addresses thinking patterns that contribute to problems in

Another approach that some consider to be within the cognitive behavioral tradition is dialectical behavior therapy (DBT [58]). DBT is an empirically supported therapy approach

established related to participation in probation and treatment of tasks.

connections are bolstered in this approach.

156 Recent Advances in Drug Addiction Research and Clinical Applications

**4.5. Cognitive behavior therapy**

adaptation.

With the rise of neuroscience and a deeper understanding of cognitive processes, contempo‐ rary neuroscience has begun to offer evidence holds some promise of informing clinical efforts. It has been suggested [60] that mechanisms associated with motivation and control elements of addictive processes are better illuminated by advances in the neurocognitive laboratory than prior models. In particular, attentional bias, reward processing, and cognitive control are important areas of research that are soon to make direct contributions to treatment. These findings are consistent with early findings related in impulse control that indicate that impulse control problems is a likely culprit in at least the exacerbation if not a cause of substance abuse problems [61]. EEG study has suggested that patterns of substance misuse may be associat‐ ed with detectable deflections in brain activity as assessed via quantitative electroencepha‐ lography (qEEG) methods [62]. The decade of the 2000s reflected increased interest in the role of executive function in a number of human problems in adaptation including substance abuse patterns. An essential element of executive function is the capacity to postpone, prevent, and/ or arrest a behavioral response to permit time for the development of more constructive paths of behavior [63].

Some facets of substance misuse phenomena are being treated with repetitive transcranial magnetic stimulation (rTMS [64]). This non-invasive method uses an electromagnetic field that changes rapidly and induces electrical currents in the brain. rTMS has been found to have promising effects on some aspects of addiction-related cognitions. While there is continued investigation into the exact mechanism of effect of rTMS, craving has been seen as an area of patient difficulty that responds to rTMS [65].

The role of dopamine represents another avenue of research/treatment progress. While the direct treatment implications are not clear, it is important to note that the emerging work in physiology indicates that substance abuse and disinhibition are different [66]. Prominent striatal dopamine has an important influence on externalizing proneness (disinhibition) and on reward-based decision-making. Using eyeblink rate as estimator of dopamine level associated with disinhibition, investigators have found that dopamine is more strongly associated how much an individual "wants" (motivation) to learn about making decisions associated with tangible rewards. This orientation to learning about decision-making is then accompanied by working with an individual's broader substance use patterns that are associated with learning of action-reward contingencies [67].

For a number of reasons consistent with the approaches just noted, psychotropic medica‐ tions have been used with some success to reduce vulnerabilities associated with substance misuse syndromes. Medication-assisted treatment (MAT) uses medications that can reduce

cravings (agonists or partial agonists), interfere with the pleasurable sensations that come from use (antagonists), or create negative feelings with a substance is taken. Methadone, buprenor‐ phine (opioid partial agonist-antagonist), and naltrexone (antagonist) have been used for opioid addiction. Antabuse has been used for alcohol since tire manufacturers noticed that workers could not drink alcohol after the vapors of the precursor of antabuse was inhaled during the vulcanization of rubber [17]. In the wake of problems associated with methadone maintenance, buprenorphine has become an effective alternative in reducing withdrawal symptoms and cravings associated with opioid dependence. For nicotine, there are three FDAapproved approaches to nicotine replacement. The FDA first approved nicotine gum (approved in 1984 and available over the counter in 1996) and the transdermal nicotine patch (approved in 1992 and over the counter in 1996) for smoking cessation. Finally, nicotine sprays (1996) and inhalers (1998) were approved for dispensing by prescription. Other psychotropic medications have been used in an off-label fashion to reduce depression and anxiety associated with recovery.

#### **4.7. Motivational interviewing**

Motivational interviewing (MI) is defined by its originators as a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence [68]. The developers of MI affirm that MI is primarily a style of relating to service recipients rather than a specific set of techniques [69]. The originators of MI explicitly described borrowing many ideas from the interpersonal therapy tradition, and MI has become a "Gold Standard" for intervention. MI concepts include a focus on the capacities of the client, maintaining positive communication, an emphasis on resolving change-related ambivalence, and appreciating the variability in change readiness. In addition, empathy is emphasized and therapeutic resistance is a force with which one collaborates, and client inconsistencies are challenged. Further, MI emphasizes engagement with clients in empathic and collaborative communication, attention to established behavior change goals, and the initiation of change planning when the client is ready. There is a growing body of empirical work that supports the efficacy of MI for substance abuse disorders [70, 71].

Despite the fact that MI is touted primarily as a style of relating to patients, literature that followed its introduction highlighted specific techniques. These techniques were not forward‐ ed as specifically essential to the approach but rather were considered to be naturally emerging and optimal examples of how the perspective might appear in practice.

#### **4.8. Efficacy of treatment approaches**

As has been discussed, various treatment approaches have developed for the treatment of substance-related disorders. In the interest of brevity, **Table 1** is presented with references pertaining to the nature of the treatment approaches and their efficacy. There are some important observations that are worth noting beyond the specifics of the table. Evidence continues to accumulate for the effectiveness of a variety of treatment approaches as well as the distinct cost advantage that treatment has over incarceration [72]. There is a continued call for "translational research" that takes findings from the laboratory and cultivates enhanced clinical practice [73]. New methods of assessing efficacy have been proposed that are more ecologically valid than traditional outcome studies, particularly emphasizing longer periods of follow-up [74].

cravings (agonists or partial agonists), interfere with the pleasurable sensations that come from use (antagonists), or create negative feelings with a substance is taken. Methadone, buprenor‐ phine (opioid partial agonist-antagonist), and naltrexone (antagonist) have been used for opioid addiction. Antabuse has been used for alcohol since tire manufacturers noticed that workers could not drink alcohol after the vapors of the precursor of antabuse was inhaled during the vulcanization of rubber [17]. In the wake of problems associated with methadone maintenance, buprenorphine has become an effective alternative in reducing withdrawal symptoms and cravings associated with opioid dependence. For nicotine, there are three FDAapproved approaches to nicotine replacement. The FDA first approved nicotine gum (approved in 1984 and available over the counter in 1996) and the transdermal nicotine patch (approved in 1992 and over the counter in 1996) for smoking cessation. Finally, nicotine sprays (1996) and inhalers (1998) were approved for dispensing by prescription. Other psychotropic medications have been used in an off-label fashion to reduce depression and

Motivational interviewing (MI) is defined by its originators as a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence [68]. The developers of MI affirm that MI is primarily a style of relating to service recipients rather than a specific set of techniques [69]. The originators of MI explicitly described borrowing many ideas from the interpersonal therapy tradition, and MI has become a "Gold Standard" for intervention. MI concepts include a focus on the capacities of the client, maintaining positive communication, an emphasis on resolving change-related ambivalence, and appreciating the variability in change readiness. In addition, empathy is emphasized and therapeutic resistance is a force with which one collaborates, and client inconsistencies are challenged. Further, MI emphasizes engagement with clients in empathic and collaborative communication, attention to established behavior change goals, and the initiation of change planning when the client is ready. There is a growing body of empirical work that supports

Despite the fact that MI is touted primarily as a style of relating to patients, literature that followed its introduction highlighted specific techniques. These techniques were not forward‐ ed as specifically essential to the approach but rather were considered to be naturally emerging

As has been discussed, various treatment approaches have developed for the treatment of substance-related disorders. In the interest of brevity, **Table 1** is presented with references pertaining to the nature of the treatment approaches and their efficacy. There are some important observations that are worth noting beyond the specifics of the table. Evidence continues to accumulate for the effectiveness of a variety of treatment approaches as well as the distinct cost advantage that treatment has over incarceration [72]. There is a continued call

anxiety associated with recovery.

158 Recent Advances in Drug Addiction Research and Clinical Applications

**4.7. Motivational interviewing**

the efficacy of MI for substance abuse disorders [70, 71].

**4.8. Efficacy of treatment approaches**

and optimal examples of how the perspective might appear in practice.



**Table 1.** Representative literature of efficacy and application of treatment approaches.

## **5. Conclusion**

The history of use of mood-altering substances is complex and controversial. For centuries, the conflict between the benefits of varied substances and the massive societal costs of the misuse of substances has been confused by political and economic motivations for action related to substance users. A contemporary response to the complexity and cost of substance-related disorders is the development of the drug court. The first drug court was created in Florida in 1989 [75] as there was growing awareness of the widespread presence of substance abusing offenders in the criminal justice system. As testimony to the appeal of the drug court con‐ cept, one may note that National institute of Justice reported that there were more than 3400 drug courts in the United States by the middle of 2014. Drug court programs consider an individual's unique patterns of use and associated consequences with a graduated series of rewards for the attainment of target behaviors. Early evidence suggests that drug courts are associated with lower recidivism [76]. Drug court may reflect the type of approach that fits the

complex and destructive influence of substance misuse. Drug court is a program that offers many services to legally mandated individuals, and it represents an intersection between several models of addiction, most notably the moral and medical models. Following a legal adjudication, a treatment and follow-up plan is created that involves the judgment and leverage intrinsic to the criminal justice system. Thus, the moral dimension of drug court serves as the "teeth" for the accountability built into the program. At the same time, the nature of the substance use problem is assessed and diagnosed by treatment facilities that work in concert with the court. Treatment is based on the prevailing diagnostic system (DSM, ICD) that reflects the specific diagnostic criteria and decision rules that characterize the medical model. With this combination of perspectives, the drug court concept may represent the interdisciplinary future of substance abuse therapeutics.
