UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

成瘾持续治疗的实施

Author
James R McKay, PhD
Section Editors
Richard Saitz, MD, MPH, FACP, DFASAM
Andrew J Saxon, MD
Deputy Editor
Richard Hermann, MD
Translators
钟娜, 主治医师

引言

对许多患者而言，成瘾是一种慢性疾病。然而，传统的成瘾治疗模式强调，进行强化治疗以达到医疗监督下的物质戒断和/或患者稳定，随后进行有时间限制的门诊治疗。近年来，公立和私立的医疗保健系统以及临床医生逐渐认识到，与糖尿病或高血压等慢性躯体疾病相似，慢性或复发性成瘾通常也需要长期持续治疗。  

成瘾的持续治疗包括常规评估，以及根据患者的需求和意愿制定个体化治疗。临床医生应对患者的临床状态和复发风险进行系统性监测。患者的成瘾情况随时间推移而时轻时重，故治疗强度也需相应调整。患者会接受自我管理技能的培训，并会得到专业支持和社区支持的其他资源。

本专题将介绍慢性或复发性成瘾持续治疗的实施，以及用于难治性患者的策略。其他专题将介绍成瘾持续治疗的适应证、持续治疗的内容及多模式持续治疗干预的效果；不同物质使用障碍(substance use disorder, SUD)特定的治疗问题；SUD患者恰当治疗等级的确定。 (参见“成瘾的持续治疗：指征、特点和效果”和“阿片类物质使用障碍的药物治疗”和“酒精使用障碍的药物治疗”和“酒精使用障碍的心理社会治疗”和“大麻使用障碍：治疗、预后及远期药理效应”和“成人可卡因使用障碍：流行病学、药理学、临床表现、医疗后果和诊断”和“Psychosocial interventions for stimulant use disorder in adults”和“如何确定治疗物质使用障碍的恰当医疗服务等级”)

一线干预

治疗强度 — 对于慢性成瘾患者，治疗强度取决于SUD的严重程度、复发风险以及患者参与治疗的意愿。在下文中，将介绍我们对于3种严重程度的SUD患者(与DSM-5亚型一致)的总体初始方法[1]。对于持续治疗的最佳频率和持续时间，目前仍缺乏研究证据[2]；下文中的建议主要是根据我们的临床经验。 (参见“成瘾的持续治疗：指征、特点和效果”，关于‘指征’一节)

这些初始的持续治疗计划是为随着治疗等级降低仍能保持戒断的患者而提出。后续阶段中，持续治疗的频率和持续时间将根据患者对早期阶段的反应来进行调整。例如，与对治疗反应良好的患者相比，对初始治疗反应较差的患者或反复复发的患者需要强度更高且持续时间更长的治疗。

                   

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2015-10-20.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  2. Blodgett JC, Maisel NC, Fuh IL, et al. How effective is continuing care for substance use disorders? A meta-analytic review. J Subst Abuse Treat 2014; 46:87.
  3. McKay JR, Lynch KG, Shepard DS, Pettinati HM. The effectiveness of telephone-based continuing care for alcohol and cocaine dependence: 24-month outcomes. Arch Gen Psychiatry 2005; 62:199.
  4. McKay JR, Alterman AI, Cacciola JS, et al. Continuing care for cocaine dependence: comprehensive 2-year outcomes. J Consult Clin Psychol 1999; 67:420.
  5. McKay JR, Van Horn DH, Lynch KG, et al. An adaptive approach for identifying cocaine dependent patients who benefit from extended continuing care. J Consult Clin Psychol 2013; 81:1063.
  6. McKay JR, Van Horn D, Oslin DW, et al. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction 2011; 106:1760.
  7. Dutra L, Stathopoulou G, Basden SL, et al. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry 2008; 165:179.
  8. Silverman K, Robles E, Mudric T, et al. A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs. J Consult Clin Psychol 2004; 72:839.
  9. Carpenedo CM, Kirby KC, Dugosh KL, et al. Extended voucher-based reinforcement therapy for long-term drug abstinence. Am J Health Behav 2010; 34:776.
  10. Marlowe DB, Festinger DS, Arabia PL, et al. Adaptive Interventions in Drug Court: A Pilot Experiment. Crim Justice Rev 2008; 33:343.
  11. Brooner RK, Kidorf MS, King VL, et al. Behavioral contingencies improve counseling attendance in an adaptive treatment model. J Subst Abuse Treat 2004; 27:223.
  12. Timko C, Debenedetti A, Billow R. Intensive referral to 12-Step self-help groups and 6-month substance use disorder outcomes. Addiction 2006; 101:678.
  13. McKay JR. Treating Substance Use Disorders With Adaptive Continuing Care, American Psychological Association Press, Washington, DC 2009.
  14. Lash SJ, Burden JL, Fearer SA. Contracting, prompting, and reinforcing substance abuse treatment aftercare adherence. J Drug Addict Educ Erad 2007; 2:455.
  15. Litt MD, Kadden RM, Kabela-Cormier E, Petry N. Changing network support for drinking: initial findings from the network support project. J Consult Clin Psychol 2007; 75:542.
  16. Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin Psychol 2011; 79:330.
  17. Gustafson DH, McTavish FM, Chih MY, et al. A smartphone application to support recovery from alcoholism: a randomized clinical trial. JAMA Psychiatry 2014; 71:566.
  18. Gustafson DH, Palesh TE, Picard RW, et al. Automating addiction treatment: Enhancing the human experience and creating a fix for the future. In: Future of Intelligent and Extelligent Health Environment, Bushko R. (Ed), IOS Press, Amsterdam 2005.
  19. Squires DD, Bryant, MD. Substance use disorders. In: Using Technology to Support Evidence-Based Behavioral Health Practices: A Clinician’s Guide, Cucciare MA, Weingardt KR. (Eds), Routledge, New York 2009.
  20. Lieber CS, Weiss DG, Groszmann R, et al. I. Veterans Affairs Cooperative Study of polyenylphosphatidylcholine in alcoholic liver disease: effects on drinking behavior by nurse/physician teams. Alcohol Clin Exp Res 2003; 27:1757.
  21. Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med 1999; 159:1946.
  22. Kristenson H, Ohlin H, Hultén-Nosslin MB, et al. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomized controls. Alcohol Clin Exp Res 1983; 7:203.
  23. Kristenson H, Osterling A, Nilsson JA, Lindgärde F. Prevention of alcohol-related deaths in middle-aged heavy drinkers. Alcohol Clin Exp Res 2002; 26:478.
  24. Miller WR, Weisner C. Integrated care. In: Changing Substance Abuse Through Health and Social Systems, Miller WR, Weisner CM. (Eds), Kluwer Academic/Plenum, New York 2002. p.243.
  25. Weisner C, Mertens J, Parthasarathy S, et al. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA 2001; 286:1715.
  26. Mertens JR, Flisher AJ, Satre DD, Weisner CM. The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug Alcohol Depend 2008; 98:45.
  27. Chi FW, Parthasarathy S, Mertens JR, Weisner CM. Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model. Psychiatr Serv 2011; 62:1194.
  28. Milby JB, Schumacher JE, Raczynski JM, et al. Sufficient conditions for effective treatment of substance abusing homeless persons. Drug Alcohol Depend 1996; 43:39.
  29. Milby JB, Schumacher JE, McNamara C, et al. Initiating abstinence in cocaine abusing dually diagnosed homeless persons. Drug Alcohol Depend 2000; 60:55.
  30. Milby JB, Schumacher JE, Wallace D, et al. Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up. J Consult Clin Psychol 2003; 71:619.