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Prochaska, DiClemente and Norcross have studied the process of change known as the Transtheoretical Model of Change, 15 although this change model was originally designed for smoking cessation it is applicable to any form of substance abuse.
Precontemplation stage - an individual may be unaware of their problem and if aware, has no intention of changing.
Contemplation stage - an individual devotes serious thought to overcoming the problem but has not yet committed to any action.
Preparation stage - an individual plans to take action within a certain time frame.
Action stage -an individual is successful in modifying their behavior.
Maintenance stage - an individual continues to change and takes action to prevent relapse. An individual who has been drug free post-6 months to 5 years is considered in this stage.
Relapse - recovery from addiction is considered a continuous process rather than a discrete event. By definition, relapse is expected in and defined as, a criterion for chemical dependency and addiction.
The dental professionals must understand which stage of change the user is in so effective communication can occur. Precontemplators have no interest in changing behavior and are also known as contented users. During this stage, our role is to communicate the message that oral health team members can serve as a referral source if the user does decide to make a quit attempt. Our greatest role is to motivate contemplators into the preparation stage of change by showing empathy and understanding of this disease. We must never be judgmental or critical. Influence is greatest during the Contemplative and Maintenance phase. By actively questioning the patient about substance use and abuse, you cause the patient to consider their current drug or alcohol problem. Patients who have entered the Maintenance phase will require dental treatment modification to avoid relapse. Patients who have relapsed should be treated, as precontemplators or contemplators and the oral health team should encourage another cessation attempt.
Today, there are several components and combinations of care commonly offered to individuals seeking or requiring treatment for substance abuse, dependency and addiction.
Individuals may require all of these components over time and some may only need a select few. Additionally, the length of stay, intensity or amount of treatment, characteristics of patient and therapist, and costs related to treatment are factors in treatment success.
Behavioral Treatments help patients engage in the treatment process, modify their attitudes and behaviors related to drug abuse, and increase healthy life skills. Behavioral treatments can also enhance the effectiveness of medications and help people stay in treatment longer.
Pharmacotherapy. Understanding the affect of different agents used in pharmacotherapy is important for the dental professional.
Buprenorphine is a relatively new and important treatment medication. NIDA-supported basic and clinical research led to the development of buprenorphine (Subutex or, in combination with naloxone, Suboxone), and demonstrated it to be a safe and acceptable addiction treatment. It is commonly used in treatment for opioid addiction. While these products were being developed in concert with industry partners, Congress passed the Drug Addiction Treatment Act (DATA 2000), permitting qualified physicians to prescribe narcotic medications (Schedules III to V) for the treatment of opioid addiction. This legislation created a major paradigm shift by allowing access to opiate treatment in a medical setting rather than limiting it to specialized drug treatment clinics. 16
Methadone, a synthetic narcotic, is used in treatment of narcotic addiction. Methadone is usually taken once per day and will nearly block the euphoric effect of heroin. Individuals can become addicted to Methadone.
Naltrexone, (Depade®, ReVia®), may also be useful in treating alcoholics. In addition, an injectable, long-acting form of naltrexone (Vivitrol®) is available. This medication acts in the brain to reduce craving for alcohol after someone has stopped drinking.
Acamprosate (Campral®) is now used in the treatment of alcoholism. It is thought to work by reducing symptoms that follow lengthy abstinence, such as anxiety and insomnia. 17
Chantix (varenicline) used in conjunction with nicotine replacement therapy and behavioral counseling has been scientifically evaluated and shown to increase quit success among smokers. According to Gonzales et al, varenicline was significantly more efficacious than placebo for smoking cessation at all time points and significantly more efficacious than bupropion SR at the end of 12 weeks of drug treatment and at 24 weeks. 18
A once commonly used medication for treatment of alcoholism; disulfiram (Antabuse®) is infrequently used today. It does not block cravings but discourages drinking by making the person taking it feel sick after drinking alcohol.
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