Running head: SUBSTANCE ABUSE AND DEPENDENCE
Substance Abuse and Dependence:
Most Common and Effective Treatment Practices
Washington University in St. Louis
Samantha Sipple and Danielle Weiss
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Scope of the Issue
Substance and alcohol abuse and dependence is a widespread national and global issue,
affecting the health, mental health, and economy of society today. According to the 2012
National Survey on Drug Use and Health (NSDUH), about 22.2 million people age 12 or older
were classified as meeting DSM-IV criteria for substance dependence or substance abuse in the
past year in the U.S. (Substance Abuse and Mental Health Services Administration (SAMHSA,
2013). Of this number, “17.7 million had alcohol dependence or abuse, and 7.3 million had illicit
drug dependence or abuse” (SAMHSA, 2013). Overall, the rate of alcohol dependence or abuse
has declined from 2002-2012 by 7.7%, going from 18.1 million people who had alcohol
dependence of abuse in 2002 to 17.7 million in 2012 (National Institute on Drug Abuse,
DrugFacts: Nationwide Trends, 2014a).
Although statistics show that rates of alcohol abuse and dependence are on the decline,
the use of illicit drugs in American has been on the rise over the past 10 years. In 2012, “an
estimated 23.9 million Americans aged 12 or older—or 9.2 percent of the population—had used
an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or
tranquilizer) in the past month” (National Institute on Drug Abuse, DrugFacts: Nationwide
Trends, 2014a). This is an 8.3% increased since 2002, and is mainly attributed to the widely
increased use of marijuana in recent years. See graph below for numbers of use of illicit drugs
types:
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Use of Illicit Drugs in the Past Month in 2012
Source: National Institute on Drug Abuse, DrugFacts: Nationwide Trends, 2014a.
In 2013, the National Institute of Health (NIH) annual Monitoring the Future survey of
8th, 10th, and 12th graders elicited information on the increased use of marijuana over the past two
decades (National Institute on Drug Abuse, Monitoring the Future, 2014b). The survey found
that as the perceived harm of marijuana has steadily decreased, the use of marijuana has steadily
increased (National Institute on Drug Abuse, Monitoring the Future, 2014b). See graphic
illustrating statistics on this phenomenon below:
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Source: National Institute on Drug Abuse, Monitoring the Future, 2014b.
Although 60% of high school students do not view marijuana use as harmful, the potency of
THC in marijuana has increased to a significantly higher level in the past few years, “which
means that use of today’s marijuana may have greater health consequences than use of marijuana
from 10 to 20 years ago (National Institute on Drug Abuse, Monitoring the Future, 2014b). As
marijuana has the highest dependence or abuse rate of all drugs after alcohol, with 4.3 million
people meeting clinical criteria of abuse or dependence in 2012, this issue is calls for heightened
attention and research in the coming years.
Another pressing current issue, especially for the St. Louis region, is the rising rate of
heroin use. Numbers have been on the rise since 2007, and according to the 2012 NSDUH,
669,000 people had used heroin in the past year (National Institute on Drug Abuse, Heroin,
2014c). Additionally, “156,000 people started heroin use in 2012, nearly double the number of
people in 2006 (90,000)” (National Institute on Drug Abuse, Heroin, 2014c). The National
Institute on Drug Abuse report on the issue of heroin highlights the issue in St. Louis as well as
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Chicago, reporting that the heroin use in these cities has been on the rise not only in urban areas,
but also in suburban and rural areas (National Institute on Drug Abuse, Heroin, 2014c). There
have been significant increases in the amount of heroin seized by officials in St. Louis, as well as
shockingly high and tragic increases in the numbers of people dying of overdose by heroin
(National Institute on Drug Abuse, Heroin, 2014c). The changing scope and prevalence of the
use of heroin is a particularly concerning and pressing issue in the US and globally, especially in
light of the serious health risks associated with use of this highly addictive drug. See graph
below for heroin use numbers:
Past Month and Past Year Heroin Use Among Persons Aged 12 or Older: 2002-2012
Source: SAMHSA, 2013.
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Economic Cost to Society
Substance abuse, including abuse of alcohol, tobacco, and illicit drugs, is highly costly to
American society, “exacting over $600 billion annually in costs related to crime, lost work
productivity and healthcare” (National Institute on Drug Abuse, Trends and Statistics, 2012).
Tobacco costs $96 billion in healthcare and $193 billion overall; alcohol costs $30 billion in
health care and $235 billion overall; and illicit drugs cost $11 billion in healthcare and $193
billion overall (National Institute on Drug Abuse, Trends and Statistics, 2012). These high costs
to the country illustrate the need for increased efforts to invest in effective prevention and
intervention programs across the US. Despite the high costs to society, a large treatment gap
continues to persist across the board, as the number of people needing treatment for substance
abuse or dependence is significantly higher than those receiving treatment (National Institute on
Drug Abuse, DrugFacts: Nationwide Trends, 2014a).
Treatment Need vs. Treatment Received
The availability and utilization of substance abuse treatment is highly disparate from the
prevalence of the need for such services. According to NSDUH, 23.5 million people age 12 and
older needed substance abuse treatment in 2009 (National Institute on Drug Abuse, DrugFacts:
Treatment Statistics, 2011). However, only 2.6 million, or 11.2%, actually received treatment at
a specialized facility (National Institute on Drug Abuse, DrugFacts: Treatment Statistics, 2011).
In 2012, 8 million people aged 12 and older needed treatment for illicit drug use, while only 1.5
million or 19.1% of those people received specialized treatment (SAMSHA, 2013). For alcohol
abuse treatment in 2012, 18.3 million people aged 12 and older needed treatment, while only 1.5
million or 8.2% received specialized treatment for the issue (SAMSHA, 2013). There is clearly
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an issue regarding the disparity between the need for and receipt of treatment for problems with
substance abuse and dependence.
From 2006-2012, NSDUH collected information on the most common reasons that those
needing treatment for substance abuse did not receive appropriate specialized services.
“Based on 2009-2012 combined data, the six most often reported reasons for not
receiving illicit drug or alcohol use treatment among persons aged 12 or older who
needed and perceived a need for treatment but did not receive treatment at a specialty
facility were (a) not ready to stop using (40.4 percent), (b) no health coverage and could
not afford cost (34.0 percent), (c) possible negative effect on job (12.0 percent), (d)
concern that receiving treatment might cause neighbors/community to have a negative
opinion (11.6 percent), (e) not knowing where to go for treatment (9.1 percent), and (f)
had health coverage but did not cover treatment or did not cover cost (7.9 percent).”
(SAMSHA, 2013).
This data presents important information regarding the barriers to receiving treatment. After not
being ready to stop using, the most common barrier to receiving treatment was lack of health
insurance and inability to afford treatment. This points to a huge issue in the field of substance
abuse: the continued stigma against those struggling with substance abuse or dependence. Due to
the stigma against and blame on people with substance abuse issues, or viewing the issue as
sinful and due to a lack of willpower or morality, there is a clear lack of funding for treatment
facilities and a failure of health insurance to cover the costs. Additionally, 9.1% of those needing
treatment did not know where to go for treatment. Together, the persisting stigma and lack of
knowledge of treatment facilities highlight the continued need for outreach, spreading awareness,
and distributing correct information to reduce stigma and advocate for more funding and more
affordable specialized treatment facilities.
Common Models and Methods for Treatment
There are various settings for substance abuse and dependence treatment. The most
common settings reported in the 2012 NSDUH are as follows, starting with the most common:
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self-help group; outpatient rehabilitation; inpatient rehabilitation; outpatient mental health center;
hospital inpatient; private doctor's office; emergency room; prison or jail (SAMHSA, 2013). See
the graph below for the numbers of people receiving treatment at each location:
Source: SAMHSA, 2013.
There are several traditional approaches upon which substance abuse treatment is
commonly based, including the medical model, the social model, and the behavioral model (U.S.
Department of Health and Human Services (HHS), 1999). The medical model views addiction as
a biological disease, and emphasizes the need for lifelong abstinence through long-term recovery
and support programs (HHS, 1999). The medical or disease model defines addiction as “a
primary, chronic, and progressive disease, probably cause by a genetic predisposition” (Fisher &
Harrison, p. 38, 2013). This approach can be compared to the way that other chronic diseases,
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such as diabetes, are viewed and treated. The social model for treatment focuses on long-term
abstinence and encourages peer support or self-help groups to maintain sobriety (HHS, 1999).
Social treatment models may be based in sociocultural or biopsychosocial models of addiction,
which view addiction in light of multiple interacting variables, including cultural, religious,
ethnic, and environmental factors (Fisher & Harrison, 2013). Lastly, the behavioral treatment
model “focuses more on diagnosis and treatment of other problems or conditions that can
interfere with recovery” (HHS, 1999). In light of behavioral theory, behavioral treatment views
addiction as a “learned and reinforced behavior” and recognizes the need for relearning and
reinforcing new behaviors that are necessary for leading a sober life (Fisher & Harrison, 2013).
This implies that behavioral treatment is based in the psychological model of addiction, which
views addiction as a symptom of other underlying psychological disorders (Fisher & Harrison,
2013).
Current Treatment Practices
A variety of practices are currently being used in the field of addiction treatment. Despite
the fact there are numerous evidence-based treatment practices in existence, treatment facilities
do not necessarily implement all of practices. Different approaches to treatment exist based on
the model of addiction to which an agency adheres (Fisher & Harrison, 2013).
Two common treatment practices for alcohol and substance use disorders involve the use
of pharmacotherapy: detoxification and aversion therapy (Fisher & Harrison, 2013; Fuller &
Hiller-Sturmhofel, 1999). Detoxification, or the process of removing toxic substances from a
person’s system, is often employed with clients who are addicted to Central Nervous System
(CNS) depressants, which have harmful withdrawal effects. The “withdrawal syndrome from
CNS depressants can be medically dangerous” and symptoms may include “anxiety, irritability,
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loss of appetite, tremors, insomnia, and seizures” (Fisher & Harrison, 2013, p. 21). Clients
undergoing withdrawal from CNS depressants may be in serious danger due to withdrawal
symptoms, and withdrawal may even be lethal. Therefore, in a clinical setting, minor
tranquilizers can be used to reduce the severity of the withdrawal symptoms. Detoxification can
provide a relief of withdrawal symptoms to clients and prevent relapse (Fisher & Harrison,
2013).
Another use of pharmacotherapy is in aversion therapy, a behavioral technique
commonly used in the treatment of problematic AOD use. Aversion therapy “seeks to develop in
the client, via classical Pavlovian conditioning, a conditioned negative response to the sight,
smell, taste and even thought of alcohol” (Fisher & Harrison, 2013, p. 140). This response is
typically achieved through the introduction of negative stimuli, which are learned to be
associated with the user’s drug of choice. This may be induced using pharmaceuticals that cause
nausea and sickness when the drug is used, such as the drug Antabuse, which is used as aversion
therapy for alcohol. In the past, shock therapy and various images have also been used as
aversion therapy (Fisher & Harrison, 2013).
Non-medication treatment practices include therapeutic models such as the Minnesota
Model, contingency management programs, motivational interviewing, brief outcome
interventions and 12-step facilitation. The Minnesota Model is comprised of four components.
The first component is the belief that clients can change their “attitudes, beliefs, and behaviors”
(Fisher & Harrison, 2013, p. 139). Secondly, the Minnesota Model aligns with the medical
model of addiction, which views addiction as a disease rather than a lack of morality or a choice.
The third component of the Minnesota Model emphasizes the importance of remaining abstinent
from mood-altering chemicals (Fisher & Harrison, 2013). The fourth component of the
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Minnesota Model is the integration of 12-step programs in treatment, such as Alcoholics
Anonymous (AA) and Narcotics Anonymous (NA) (Fisher & Harrison, 2013). The Minnesota
Model is one of the most widely used treatment approaches for severe substance abuse across the
U.S. (Winters, Stinchfield, Opland, Weller, and Latimer, 2000).
Other common current treatment practices include programs such as AA and NA, which
are commonly referred to as 12-step programs and have a heavy emphasis on peer support and
spirituality (Center for Substance Abuse Treatment, 1997; Fisher & Harrison, 2013; Fuller &
Hiller-Sturmhofel, 1999). Treatment practices that emphasize behavioral change include
contingency management plans and cognitive behavioral therapy (Center for Substance Abuse
Treatment, 1997; Fisher & Harrison, 2013). Lastly, brief interventions are used in primary care
settings for people who may be presenting drinking problems or are at a higher risk of
developing substance abuse or dependence (Fuller & Hiller-Sturmhofel, 1999, p. 76). Brief
interventions differ from therapeutic interventions in that brief interventions are more focused on
motivating a client to make a particular change or perform a particular action, such as entering
treatment or changing a behavior (Center for Substance Abuse Treatment, 1999).
Effectiveness of Current Practices
Pharmacotherapy practices are commonly used to treat AOD disorders. Medications
frequently prescribed to treat AOD disorders include Methadone, Buprenorphine, Antabuse,
Naltrexone, and Acamprosate (Fisher & Harrison, 2013). “Therapists primarily use two types of
medications in alcoholism treatment: (1) aversive medications, which deter the patient from
drinking, and (2) anticraving medications, which reduce the patient’s desire to drink” (Fuller &
Hiller-Sturmhofel, 1999, p. 75). Fuller & Hiller-Sturmhofel (1999) conducted a study that
analyzed the effectiveness of pharmacotherapy and therapeutic practices. Antabuse is a common
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drug used to treat alcohol use disorders. Researchers found that poor compliance taking
Antabuse nullified its effectiveness (Fuller & Hiller-Sturmhofel, 1999). Researchers recommend
client supervision from therapists or family members to be most effective for clients taking
Antabuse. Fuller & Hiller-Sturmhofel (1999) also studied the effects of anticraving medications
such as Naltrexone and Acamprosate. Research revealed Naltrexone has been effective at
resulting in a reduction in relapse rates, whereas Acamprosate treatment has been shown to
double the abstinence rate among recovering alcoholics (Fuller & Hiller-Sturmhofel, 1999).
Thus, certain pharmacotherapy approaches can be effective treatment methods for substance
abuse and dependence.
When analyzing the effectiveness of therapeutic approaches, Fuller & Hiller-Sturmhofel
(1999) conducted a multisite study designed to identify patient characteristics that would predict
the most beneficial treatment approaches for alcohol abuse. Two groups of participants made up
the sample–the aftercare sample and the outpatient sample. Participants were randomly assigned
to receive Cognitive Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), or
Twelve-Step Facilitation Therapy (TSF). Interventions were administered over 12-weeks in
individual outpatient sessions. In the aftercare sample, “no differences were found in the efficacy
of CBT, MET, and TSF during the year following treatment” (Fuller & Hiller-Sturmhofel, 1999,
p. 74). However, differences that did exist favored TSF as the most effective practice to maintain
client abstinence from alcohol use (Fuller & Hiller-Sturmhofel, 1999). Additionally, brief
interventions implemented by a primary care physician have been shown to be “effective in
reducing drinking among people who have alcohol-related problems or who are at risk for such
problems” (Fuller & Hiller-Sturmhofel, 1999). Overall, CBT, MET, TSF, and brief interventions
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are effective and valuable treatment options for substance abuse and dependence and can be
utilized in a variety of settings, including inpatient, outpatient, and doctor office settings.
Treatment Demographics
As previously mentioned, “23.5 million persons aged 12 or older needed treatment for an
illicit drug or alcohol abuse problem in 2009” (National Institute on Drug Abuse, 2011). Of
these, the NSDUH study discovered only 2.6 million, or 11.2%, of those who needed treatment
received it at a specialty facility. In 2008, there was a reported 1.8 million admissions to
rehabilitation facilities. Alcohol use accounted for the majority of treatment admissions at
41.4%. Additionally, “heroin and opiates accounted for the largest percentage of drug-related
admissions (20.0%), followed by marijuana (17.0%)” (National Institute of Drug Abuse, 2011).
According to the National Institute on Drug Abuse (2011), 60% of admissions were
White, 21% African American, 13.7% Hispanic, 2.3% American Indian or Alaska Native, 1.0%
Asian/Pacific Islander, and 2.3% identified as other. Data shows that younger adults are at a
greater risk for developing a substance use disorder. In fact, “the age range with the highest
proportion of treatment admissions was the 25-29 age group at 14.8%, followed by those aged
20-24 at 14.4% and those 40-44 at 12.6%” (National Institute on Drug Abuse, 2011). In stark
contrast, persons 65 and older accounted for less than 1% of admissions. Moreover, persons
under the age of 18 accounted for approximately 7% of all clients in substance abuse treatment
facilities (National Institute on Drug Abuse, 2011).
The 2012 National Survey of Substance Abuse Treatment Services (N-SSATS) surveyed
14,311 substance abuse treatment facilities nationwide. The survey revealed that both the total
number of substance abuse facilities and the number of clients in treatment increased by 5%
between 2008 and 2012. In terms of specific interventions, the number of clients receiving
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methadone treatment increased 3% during this time frame. In addition, clients receiving
buprenorphine ranged from 1-3% in the period of 2008 to 2012 (N-SSATS, 2012).
The N-SSATS (2012) also polled treatment facilities to gather information about specific
client types most frequently served. According to the N-SSATS (2012), the most common types
of clients in treatment facilities are: clients with co-occurring disorders (5,288), adult women
(4,470), DUI/DWI offenders (4,107), adolescents (4,008), and adult men (3,550). Other client
types include criminal justice clients, persons who have experienced trauma, pregnant or
postpartum women, persons with HIV/AIDS, veterans, seniors, LGBTQ individuals, active duty
military and members of military families (N-SSATS, 2012). The survey also found that the
majority of clients, 11,764, fell within the “any program or group” category, which is an open
group (N-SSATS, 2012).
Cultural Considerations in Treatment
It is important to consider how factors of diversity impact clients’ treatment and recovery
processes. Treatment for diverse groups such as racial minorities, elderly and adolescents,
persons with disabilities, pregnant women and mothers, the criminal justice population, and
persons with co-occurring disorders should be carefully adjusted and adapted to ensure that the
populations’ particular needs are met and that they receive culturally sensitive, high quality
services. Therefore, when working with ethnically diverse populations, it may be important to be
mindful of the diversity of the treatment staff in an effort to increase client comfort. When
working with individuals from differing backgrounds, treatment staff should be aware that “the
attitude of an ethnic group toward AOD problems may present a barrier for the individual
seeking treatment” and find ways to approach that issue in a culturally sensitive manner (Fisher
& Harrison, 2013, p. 153).
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For example, in the African American community, some may view alcoholism as
immoral (Fisher & Harrison, 2013). In a study conducted by Acevedo et al. (2012), African
American clients were 14% less likely to initiate treatment for AOD use than white clients. It is
imperative that treatment facilities address potential barriers to treatment and assess whether or
not they administer culturally sensitive and appropriate care. In an effort to ensure individuals
from varying cultures receive adequate care, “substance abuse screening in medical settings
should continue to be promoted for all patients, and this may play an especially strong role in
increasing access to treatment in minority [populations]…” (Acevedo et al, 2012, p. 14). This
data again shows the importance of the role of primary care practitioners in the continuum of
AOD treatment.
Providing services to the elderly population brings about unique challenges. Specifically,
society tends to hold more lenient attitudes toward elders who use AOD, which places this
population at greater risk for developing a substance use disorder (Fisher & Harrison, 2013).
Elderly individuals have a slower metabolism, which is important to consider because it impacts
tolerance. Another factor to consider is that members of this population are beginning a new
phase in life with retirement and often the loss of loved ones. Elderly individuals may be dealing
with issues of bereavement from the loss of a spouse or friend, which could lead to the use of
AOD as a coping mechanism (Fisher & Harrison, 2013).
Persons with disabilities represent another vulnerable population in the AOD use field.
Treatment programs may require clients to complete extensive reading and writing exercises,
which may be difficult for persons with learning disabilities (Fisher & Harrison, 2013). For
persons with physical disabilities, AOD use may serve as a coping mechanism for loss of
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autonomy or independence. Furthermore, treatment programs may not accommodate the hearing
impaired, seeing impaired, or low literacy level clients (Fisher & Harrison, 2013).
Pregnancy is a unique challenge to women in treatment settings. However, “familycentered approaches such as family drug courts and residential treatment for pregnant and
parenting women have shown promising results” (Stevens et al., 2009, p. 354). The prevalence
of extensive trauma history is particularly high for women with substance abuse issues. Many
women may present with Post-Traumatic Stress Disorder (PTSD) symptoms in treatment settings
as a result. Research has shown women-only treatment centers are not more effective than
mixed-group treatment centers, but should be taken into consideration when addressing sensitive
topics in therapy such as unresolved trauma, pregnancy, and parenting (Fisher & Harrison, 2013;
Stevens et al., 2009).
The criminal justice population is often referred to Drug Court and DUI School as a
means of treatment for problematic AOD use. These methods of treatment are often short-term
solutions and lack comprehensive care. Additional “comprehensive service, community links and
aftercare services” (Fisher & Harrison, 2013, p. 158) are needed for this population. Research
has shown that the criminal justice system can provide incentive for inmates to participate in
treatment because doing otherwise may mean a return to prison or jail (Acevedo et al., 2012).
However, coercion into treatment is problematic because it eliminates clients’ autonomy and
right to self-determination, and also clients may lack the internal motivation needed for
successful treatment.
Lastly, treatment of clients with co-occurring disorders is unique and requires special
attention of its own. Other mental disorders are often viewed as secondary to the substance use
disorder. As a result, clients with severe psychiatric problems can be viewed as inappropriate for
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AOD use treatment programs (Fisher & Harrison, 2013). To further complicate the treatment
process, the effects of AOD use can mimic schizophrenia and other mental disorders, making it
difficult for clinicians and doctors to discern the etiology of clients’ behavior (Fisher & Harrison,
2013). Detoxification may be necessary to provide an accurate diagnosis. A team approach
comprised of mental health counselors and addiction counselors would effectively address
clients’ needs with co-occurring disorders (Fisher & Harrison, 2013).
Conclusion
It is clear that substance abuse disorders continue to be a prevalent and pressing problem
across the U.S. Although the issue is widespread and cuts across racial, socioeconomic, and
geographical barriers, there continues to be a glaring gap in the numbers of people who need
AOD treatment and the number of those who receive it. Fortunately, research continues to point
to many effective treatment practices for substance abuse and dependence. Pharmacotherapy,
behavioral approaches, cognitive-behavioral therapies, motivation enhancement therapy, 12-step
facilitation, and brief interventions are all effective in treating people struggling with substance
abuse and dependence. It is critical to ensure that whichever evidence-based practice is utilized,
that the practitioner takes care to meet the particular cultural differences of the individual client
and approaches treatment from a culturally sensitive perspective. Lastly, as the substance abuse
field continues to grow and change, it is essential for substance abuse practitioners to stay current
with best practices in the research and remain adaptable and flexible to trends in the field.
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References
Center for Substance Abuse Treatment. (1997). A Guide to Substance Abuse Services for
Primary Care Clinicians. Rockville, MD: Substance Abuse and Mental Health Services
Administration.
Center for Substance Abuse Treatment. (1999). Brief Interventions and Brief Therapies for
Substance Abuse. Rockville (MD): Substance Abuse and Mental Health Services
Administration (US). (Treatment Improvement Protocol (TIP) Series, No. 34.) Chapter
1—Introduction to Brief Interventions and Therapies. Retrieved from:
http://www.ncbi.nlm.nih.gov/books/NBK64950/
Fuller, K.R., Hiller-Strmhofel, S. (1999). Alcoholism Treatment in the United States. Alcohol
Research & Health, 23(2), 69-77.
Fisher, G.L., and Harrison, T.C. (2013). Substance Abuse: Information for School Counselors,
Social Workers, Therapists, and Counselors. Boston, MA: Pearson.
Acevedo, A., Garnick, D.W., Lee, M.T., Horgan, C.M., Ritter, G., Panas, L., Davis, St. Leeper,
T., Moore, R., Reynolds, M. (2012). Racial and Ethnic Differences in Substance Abuse
Treatment Initiation and Engagement. Journal of Ethnicity in Substance Abuse, 11, 1-21.
Stevens, S.J., Andrade, R., Ruiz, B.S. (2009). Women and Substance Abuse: Gender, Age, and
Cultural Considerations. Journal of Ethnicity in Substance Abuse, 8, 341-358.
National Institute on Drug Abuse. (2011). DrugFacts: Treatment Statistics. Retrieved from
http://www.drugabuse.gov/publications/drugfacts/treatment-statistics.
National Institute on Drug Abuse. (2012). Trends and Statistics. Retrieved from
http://www.drugabuse.gov/related-topics/trends-statistics#costs.
SUBSTANCE ABUSE AND DEPENDENCE
19
National Institute on Drug Abuse. (2014a). DrugFacts: Nationwide Trends. Retrieved from
http://www.drugabuse.gov/publications/drugfacts/nationwide-trends.
National Institute on Drug Abuse. (2014b). Monitoring the Future 2013 Results. Retrieved from
http://www.drugabuse.gov/related-topics/trends-statistics/infographics/monitoring-future2013-survey-results.
National Institute on Drug Abuse. (2014c). Heroin. Retrieved from
http://www.drugabuse.gov/publications/research-reports/heroin/scope-heroin-use-inunited-states.
Substance Abuse and Mental Health Services Administration. (2012). National Survey of
Substance Abuse Treatment Services (N—SSATS): 2012. Data on Substance Abuse
Treatment Facilities. BHSIS Series S-66, HHS Publication No. (SMA) 14-4809.
Rockville, MD: Substance Abuse and Mental Health Services Administration.
Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012
National Survey on Drug Use and Health: Summary of National Findings, NSDUH
Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse
and Mental Health Services Administration. Retrieved from
http://samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUH
results2012.htm#ch7.1
U.S. Department of Health and Human Services. (1999). Understanding Addiction, Substance
Abuse Treatment, and Recovery. Blending Perspectives and Building Common Ground:
Report to Congress on Substance Abuse and Child Protection. Retrieved from
http://aspe.hhs.gov/hsp/subabuse99/chap2.htm.