Mental and behavioral disorders due to psychoactive substance use. Harmful use: clinical guidelines

List of Abbreviations

ALT – alanine aminotransferase

AST – aspartate aminotransferase

HIV/AIDS – human immunodeficiency virus / acquired immunodeficiency syndrome

WHO – World Health Organization

Gamma-GT – gamma-glutamyl transferase

IPP – individual psychotherapeutic program

ICA – immunochemical assay

SI – short-term intervention (short-term psychotherapeutic intervention)

CBT – cognitive behavioral therapy

Ministry of Health of the Russian Federation – Ministry of Health of the Russian Federation

MI – motivational interviewing

ICD-10 – International Classification of Diseases, 10th Revision

MP – motivational psychotherapy

psychoactive substance – psychoactive substance

PP – psychotherapeutic plan

HU – harmful use

DS – dependence syndrome

CST – coping skills training

AUDIT – The Alcohol Use Disorders Identification Test

CDT – carbohydrate-deficient transferrin

DUDIT – Drug Use Disorders Identification Test

SOCRATES – The Stages of Change Readiness and Treatment Eagerness Scale

MCV – mean corpuscular volume

Terms and Definitions

Patient's request in psychotherapy – the desired goal of changes subjectively perceived by the patient, which the patient intends to achieve as a result of psychotherapy.

Individual psychotherapeutic program (IPP) – a set of optimal methods of individual, group, and family psychotherapy, as well as measures to create a therapeutic environment taking into account the personal and psychopathological characteristics of the patient. The IPP is aimed at treating harmful use and related comorbid mental disorders.

Cognitive rehabilitation (cognitive training) – behavioral training focused on achieving sustained improvement in cognitive processes (attention, memory, executive functions, social cognition, and metacognition) and generalization of acquired skills in the habitual environment.

Non-specific therapeutic factors – basic treatment mechanisms that do not depend on the psychotherapy method and determine the outcomes of psychotherapy: extratherapeutic factors (patient and environment factors), therapist factors, expectancy effects, therapeutic alliance, and psychotherapy process factors.

Psychoactive substance – a substance of natural or synthetic origin capable of causing desired effects from the user's perspective upon single administration, and mental and physical dependence upon systematic use.

Psychodiagnostic assessment – the use of standardized psychodiagnostic tools, structured and semi-structured interviews, etc., to assess the patient's characterological features, cognitive functions, current emotional state, motivational sphere, and the presence of comorbid mental disorders and psychoactive substance use disorders.

Psychological counseling – a set of procedures aimed at helping a person resolve problems and make decisions regarding professional career, marriage, family, personal development, and interpersonal relationships.

Psychotherapeutic contract – a mutual agreement between the therapist and the patient regarding the conditions of psychotherapy (number of sessions, format), the therapeutic process itself (how psychotherapy will be conducted), and the outcome of psychotherapy (what changes should occur).

Psychotherapy – a planned and organized intervention aimed at influencing behavior, mood, and emotional response patterns to various stimuli using verbal and non-verbal psychological means.

Psychotherapy for harmful use – targeted professional assistance in changing and restoring the healthy state of the organism through psychological means; aimed at eliminating personal, affective, behavioral, and other disorders, optimizing the patient's interpersonal relations, and strengthening motivation to participate in the treatment program and abstain from psychoactive substances.

Mindfulness techniques – techniques that promote attention and mindfulness, i.e., the ability to non-judgmentally, specifically, and literally be aware of one's life experience while simultaneously realizing that the experienced sensations represent an internal mental image of the experience rather than objective reality.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Harmful use of a psychoactive substance (PAS) is a pattern of substance use that causes damage to health. The damage may be physical (for example, in the case of hepatitis resulting from self-administration of intravenous drugs) or mental (for example, in the case of secondary depressive disorders following heavy alcoholization).

Synonyms: substance use with harmful consequences.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

It is currently established that psychoactive substances manifest their effects in three main areas [1]:

1. By affecting specific brain systems and structures, they cause dependence;

2. Psychoactive substances (PAS) are toxic, meaning they are capable of damaging all organs and systems of the body;

3. Parental substance use affects the development of addiction in offspring and the onset of behavioral disorders such as aggressiveness, affective pathology, and deviant forms of behavior, while also diminishing children's adaptive capacities.

In the development of harmful use (HU) as the primary (most frequently observed) manifestation of PAS dependence syndrome, a significant role is played by biological, genetic, personal, familial, and environmental factors (it must be understood that this division is somewhat conventional, since genetic, personal, and familial factors are also biological in nature).

1.3 Epidemiology of the Disease or Condition

According to the World Health Organization (WHO), harmful use ranks 5th among the leading causes of premature death and disability worldwide, accounting for approximately 2.5 million deaths annually, or 3.7% of total mortality [2]. Morbidity associated with alcohol harmful use accounts for 4.4% of total morbidity [3].

In 2020, specialized institutions of the Russian Ministry of Health recorded 1,766,065 patients with mental and behavioral disorders associated with PAS use, representing 1.2% of the country's total population. As in previous years, the majority of registered patients were individuals with alcohol dependence syndrome and alcohol harmful use (77.6% of the total number of registered patients) [4].

The national addiction treatment service registered 181,792 patients with harmful alcohol use in 2020, or 123.9 per 100,000 population [4].

Overall, compared to 2016, all indicators related to visits for alcohol-related disorders declined in 2020. Specifically, the visit rate for alcohol harmful use decreased over this period from 203.7 to 123.9 per 100,000 population, a drop of 39% [4].

In 2020, the country's addiction treatment facilities registered 381,505 patients with drug addiction, or 260.0 per 100,000 population (compared to 273.4 in 2019). Compared to 2019, this indicator decreased by 4.9%. Of the total number of registered patients in 2020, the number of patients diagnosed with "harmful drug use" was 157,388, or 107.3 per 100,000 population (compared to 138.8 in 2016). Compared to 2016, this indicator decreased by 22.7% [4].

Along with the decrease in the incidence of drug addiction, there is also a decline in patient visits regarding harmful drug use: the indicator for 2019 decreased by 16.1% (from 19.9 to 16.7 per 100,000 population, respectively) [4].

The total visit rate for individuals using non-narcotic PAS in 2020 was 9.4 per 100,000 population. Additionally, 8,412 individuals sought outpatient addiction care for harmful use of non-narcotic psychoactive substances in 2020 (compared to 16,880 in 2015), representing 5.7 patients per 100,000 population. The visit rate for harmful use decreased by 10.9% compared to 2016 (9.4) [4].

Over the period from 2016 to 2020, changes have been observed in the structure of drug use among the population, including use with harmful consequences. In recent years, both in Russia and globally, there has been a decline in the proportion of patients using opioids and an increase in the proportion of patients using psychostimulants and various combinations of narcotic drugs [4]. According to the United Nations, in 2020, approximately 209 million people worldwide used cannabis (4% of the population); 21.5 million people used cocaine (0.4% of the population); and amphetamines remain the second most widely used drug globally. Cases of harmful use of new psychoactive substances are increasing. In 2020, 548 new PAS were registered, with 77 substances identified for the first time [2].

1.4 Features of Coding the Disease or Condition

1.5 Classification of the disease or condition

Not applicable.

1.6 Clinical presentation of the disease or condition

Not applicable.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis:

The diagnosis is established by taking an anamnesis (history of life and illness); performing a systematic general physical examination of the patient by organ systems; carrying out other medical procedures (measuring blood pressure, pulse, respiratory rate, etc.); and conducting a clinical psychopathological examination.

2.1 Complaints and Anamnesis

Comments: The following diagnostic criteria for harmful psychoactive substance use are taken into account.

1. PAS use has caused (or substantially contributed to) physical or mental harm to the patient, including impaired judgment or dysfunctional behavior.

2. PAS use may lead to disability or have adverse consequences for interpersonal relationships.

3. The harm must be attributable to the use of PAS.

4. The pattern of PAS use has persisted for at least 1 month or occurred repeatedly over a 12-month period.

5. The disorder does not meet the criteria for any other mental or behavioral disorder related to the use of the same psychoactive substance during the same period (except for acute intoxication).

When diagnosing physical or mental harm to health, it should be borne in mind that acute intoxication in itself does not constitute sufficient evidence of health damage required to establish such a diagnosis.

ICD-10 notes that the fact that PAS use causes disapproval from another person or society in general, or may lead to socially negative consequences such as arrest or divorce, does not in itself constitute evidence of PAS harmful use (Table 1).

Table 1 - Criteria for diagnosing F1x.1

2.2 Physical Examination

Although physical examination findings are not specific for harmful use (HU), a thorough medical examination serves as an adjunctive and confirmatory tool in clinical diagnosis and helps establish baselines for assessing the severity of the condition. For instance, in opioid harmful use, one may detect intravenous injection marks along superficial veins, decreased pain and tactile sensitivity in the extremities, miosis, and sluggish pupillary light reflex. In alcohol harmful use, findings may include conjunctival injection, sluggish pupillary light reflex, tremor, and hepatomegaly.

2.3 Laboratory Diagnostics

Clinical diagnosis is of primary importance when establishing a diagnosis of HU. Laboratory diagnostics become necessary when there is difficulty identifying psychoactive substances based on the clinical picture, when conducting differential diagnosis (Appendix A3.13), and to confirm the fact of psychoactive substance use.

Laboratory biomarkers reflect the fact of psychoactive substance use, but do not allow establishing a diagnosis of "Harmful use". On the other hand, they serve as an important objective indicator to complement classical clinical diagnostics.

Biomarkers of alcohol abuse can be divided into direct and indirect [19].

1. Indirect biomarkers:

   • determination of aspartate aminotransferase activity in blood (AST);

   • determination of alanine aminotransferase activity in blood (ALT);

   • determination of gamma-glutamyl transferase activity in blood (gamma-GT);

   • qualitative and quantitative determination of carbohydrate-deficient transferrin (CDT) in blood serum by capillary electrophoresis;

   • determination of erythrocyte dimensions (specifically, mean corpuscular volume of erythrocytes (MCV));

   • others.

2. Direct biomarkers (possessing 100% specificity):

   • quantitative determination of a single group of psychoactive substances, including narcotic drugs and psychotropic substances, and their metabolites in blood/urine by immunochemical assay;

   • testing for blood ethanol and methanol levels;

   • testing for breath ethanol levels;

   • quantitative determination of ethyl glucuronide in urine;

   • quantitative determination of phosphatidylethanol in blood.

Comments: In alcohol harmful use, altered gamma-GT activity is detected in 50–90% of cases. However, similar shifts are also observed in 10% of healthy individuals. The sensitivity and specificity of the method are 80% [1].

Comments: AST can be a moderately sensitive and specific test for identifying individuals engaging in hazardous alcohol use. According to domestic researchers, AST activity at the upper limit of normal of 40 IU/L in a group of individuals with clinically established habitual heavy drinking averaged 62.3±15.3 IU/L, in patients with stage I alcohol dependence – 46.3±2.2 IU/L, in stage II – 68.1±9.1 IU/L, and in stage III – 92.6±14.5 IU/L. Similar features are noted by foreign authors [27; 28; 29]. The sensitivity of the method reaches 56%, and specificity – 80% [1].

The AST/ALT ratio (De Ritis ratio) is frequently used in clinical practice to detect alcohol abuse (the normal range for the De Ritis ratio is 0.91–1.75; a De Ritis ratio value of less than 1 indicates liver damage).

Comments: Elevated MCV may also indicate alcohol harmful use, but it lacks high specificity as it occurs in nutritional deficiencies and other pathological conditions [23; 25].

Comments: Daily alcohol intake exceeding 60 g of ethanol for at least a week is accompanied by a noticeable increase in plasma CDT levels. Foreign studies have shown that alcohol consumption above 50–80 g/day for 2–3 weeks manifests as an increase in serum CDT levels [30]. Based on CDT determination results obtained in Russia and other countries [1; 30], researchers recommend using this test to identify alcohol abuse, including alcohol harmful use, when monitoring patients during treatment and for remission quality control. Currently, laboratory practice evaluates CDT levels without sex stratification. Up to 1.3% is normal, greater than 1.6% indicates harmful use, and the 1.3–1.6% range requires repeat testing [33]. It should be borne in mind that an elevated CDT level will not be observed immediately after the last alcohol consumption, but 1.5–2 weeks later. The time required for the parameter to normalize after cessation of use averages 4 weeks.

When screening for harmful use or alcohol dependence, the sensitivity/specificity of CDT is generally higher than that of AST, ALT, and gamma-GT [23; 29; 30].

Some studies indicate that using AST, gamma-GT, and CDT biomarkers in combination is most effective as a screening method [34]. The combined use of gamma-GT and CDT demonstrates higher diagnostic sensitivity/specificity, as well as a stronger correlation with actual alcohol consumption volumes [23]. This approach is cost-effective and easy to apply, making it suitable for routine clinical practice.

Comments: When conducting breath alcohol testing, technical measuring instruments are used whose type is included in the Federal Information Fund for Ensuring the Uniformity of Measurements [38; 39].

Determining the blood alcohol concentration in expired air itself confirms the fact of its consumption, but diagnosing alcohol use disorders requires the presence of other diagnostic criteria.

Blood alcohol measurement can be useful if the patient is intoxicated but denies alcohol abuse. The short half-life of alcohol limits its use as a biomarker. Blood alcohol levels determine consumption over the preceding several hours, which may not indicate chronic alcohol abuse, but may indicate harmful use.

Comments: After complete cessation of alcohol intake, ethyl glucuronide can be detected in urine for up to 5 days.

Comments: Laboratory diagnostics of psychoactive substances utilize two main types of testing: preliminary immunochemical assay (ICA) (specifically immunochromatographic testing using test strips) and gas chromatography as confirmatory methods.

Immunochromatographic assay is used as initial screening due to its ease of use and low cost. Chromatography is used in complex diagnostic cases to confirm immunochromatographic results and obtain high-precision findings. Chromatographic methods are highly accurate but more expensive, technically complex, and time-consuming. At the same time, it should be noted that not all groups of psychoactive substances can be detected by preliminary ICA methods (e.g., synthetic cannabinoids, various non-medically used medications, etc.)

Positive results of preliminary ICA must be followed by confirmatory testing using gas chromatography.

Comments: Detecting an infectious disease is not in itself a diagnostic criterion for harmful use (HU), but often may indicate injection drug use with a shared syringe. This can complement the clinical picture and be considered as direct harm to the patient's physical state.

2.4 Instrumental Diagnostics

The potential for instrumental diagnostics in HU is limited, as there are no specific physical and laboratory signs characteristic of HU. Instrumental methods are performed according to clinical indications.

Psychoactive substance (PAS) abuse negatively affects the central nervous system (CNS) and is associated with the development of numerous somatic comorbidities; therefore, the following examinations may be useful: ultrasound examination of internal organs, electroencephalography, echoencephalography, skull and chest X-rays, etc.

2.5 Other Procedures

Comments: The AUDIT test, recommended by the WHO (Appendix G1), is used to detect harmful alcohol use and justify interventions (psychotherapeutic and pharmacological) aimed at reducing or stopping alcohol consumption, thereby reducing the risk or avoiding harmful health consequences (disease progression and complications), and preventing the development of dependence syndrome. This test is intended primarily for psychiatrists-narcologists, but it can also be used by other specialists who encounter individuals with alcohol problems. The AUDIT test is completed by the patient, after which the physician analyzes the results and develops recommendations. A score in the range of 16-19 points indicates the zone of hazardous and harmful alcohol use.

Comments: The DUDIT test (Appendix G2) is intended primarily for psychiatrists-narcologists, but it can also be used by other specialists who encounter individuals with drug problems. The DUDIT test is completed by the patient, after which the physician analyzes the results and develops recommendations. A score of 6 points or more for men and 2 points or more for women indicates the zone of harmful drug use. A score of 25 points or higher indicates a high probability of drug dependence.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. Pharmacotherapy

3.1.1. Opiate receptor blockers

#Naltrexone** and #nalmefene in patients with harmful alcohol use reduce euphoria from alcohol consumption, which in turn decreases secondary indicators of use intensity: frequency of alcohol consumption and number of heavy drinking days.

Comments: The efficacy of #naltrexone** in the treatment of harmful alcohol use has been demonstrated in randomized controlled trials: it reliably reduces the euphorigenic effect of alcohol, the number of heavy drinking days, the frequency of alcohol consumption, and excessive alcohol use [351-357].

The starting oral dose of #naltrexone** is 25 mg for the first 4–5 days, followed by 50 mg daily [351-357]. The duration of therapy is at least 3 months [351-357]. At therapeutic doses, in patients whose bodies do not contain opioids, #naltrexone** generally does not cause serious side effects. Treatment efficacy increases when combined with psychotherapy [351-357].

The most complex problems of maintaining compliance and retaining the patient in the therapeutic program can be solved by prolonged-release forms of #naltrexone**. Extended-release #naltrexone** is a formulation intended for intramuscular administration. The drug is administered once a month, and its duration of action is 4 weeks. The duration of treatment ranges from 3 to 6 months, after which the issue of potentially extending the drug therapy is decided [351-357]. Complete abstinence from alcohol is the goal of treatment with extended-release #naltrexone**, but it should not be put forward as an absolute requirement; if the patient agrees to treatment but continues to drink periodically, this does not mean that treatment should be discontinued: some patients, especially at the initial stages of treatment, respond to #naltrexone** not by stopping, but only by reducing alcohol intake.

Absolute contraindications to prescribing #naltrexone** are hepatic impairment and acute hepatitis. Relative contraindications include elevated bilirubin levels, pregnancy, breastfeeding, and adolescence. In such cases, the physician makes a decision by assessing the situation based on the risk-benefit principle.

Comments: The only drug registered in the Russian Federation taken "as needed" intended to reduce alcohol consumption rather than complete abstinence from it is #nalmefene. Three registration studies have demonstrated high efficacy of #nalmefenein reducing the amount of alcohol consumed and the number of heavy drinking days, as well as a favorable adverse event profile [362-364]. The drug reduces the number of heavy drinking days per month by 64% over 1 year and is effective starting from 1 month and for up to 1 year. The dosing regimen is 1 tablet (18 mg) per day. In addition, the "as needed" dosing principle can be used (1 tablet 1.5–2 hours before drinking).

3.1.2. Antiepileptic drugs

Comments: The results of multicenter and randomized controlled trials show that #topiramate** reduces alcohol consumption and alcohol abuse in people with harmful alcohol use whose goal was to quit drinking. In the treatment of patients with harmful alcohol use whose treatment goal was to reduce alcohol consumption to a safe level, #topiramate** significantly reduced the number of heavy drinking days and increased the number of abstinent days compared to placebo. Patients treated with #topiramate** also had lower concentrations of the enzyme γ-glutamyltransferase and lower scores on alcohol-related problems than the placebo group. In a sub-sample of Europeans and Americans, the effect of #topiramate** on heavy drinking days was significantly higher than the placebo effect only in homozygotes for the C-allele rs2832407 [360; 361].

Recommended doses of #topiramate** are 200-300 mg per day [360; 361]. For all patients diagnosed with harmful use, the use of antiepileptic drugs is not recommended in cardiac conduction disorders; renal or hepatic impairment; blood and bone marrow disorders; water-electrolyte imbalances; glaucoma; in combination with MAO inhibitors and within 2 weeks after their withdrawal; in the first trimester of pregnancy and during lactation. They should be prescribed with caution in elderly patients, hypothyroidism, prostatitis, and patients prone to allergic reactions.

3.2 Non-pharmacological therapy

In the treatment of harmful use, the emphasis is placed on the use of psychotherapeutic programs [66-73]. Medications are prescribed according to strict indications.

The goal of harmful use therapy: achievement of a state of recovery by the patient [54], which is assessed in terms of reducing the harm caused by habitual psychoactive substance use; formation of a significant reduction in use or cessation of psychoactive substances; abstinence from psychoactive actions and objective changes in harmful use behavioral patterns [75; 76].

The objective of therapy: prevention of the development of dependence syndrome.

Therapy tactics: conducting comprehensive psychotherapeutic and, if necessary, pharmacological treatment.

Algorithm of therapeutic measures includes: (1) conducting psychotherapy; (2) prescribing pharmacotherapy as indicated; (3) prescribing therapy aimed at treating somatic disorders as indicated; (4) monitoring the condition.

It is necessary to correlate the "risk-benefit" indicator, since the likelihood of side effects and complications from the use of medicinal products increases significantly due to the possible presence of psychoactive substances and their metabolites in the body.

The pragmatic goals and objectives of therapy are determined by a number of factors, the most significant of which are:

1. The nature of harmful consequences of psychoactive substance use (acute/chronic);

2. Sociodemographic characteristics of the patient;

3. The level of personal and social functioning of the patient (characterological features; features of the emotional and cognitive-intellectual sphere; features of the motivational sphere, volitional qualities; features of family and interpersonal relations);

4. Presence of comorbid mental or somatic diseases;

5. Presence of suicidal risk;

6. The stage of the change process the patient is at, and the corresponding level of motivation and readiness for change;

7. Presence of specific problem areas requiring primary psychotherapeutic work.

Based on these factors, targets of psychotherapy are identified—dysfunctional phenomena subject to correction within the framework of the psychotherapeutic relationship, i.e., the goals of interaction understood by the therapist [77-81] (Appendix A3.1).

Psychotherapy for harmful use implies the mandatory formation of nonspecific therapeutic factors of treatment [80; 82; 83], which do not depend on the method of psychotherapy applied (Appendix A3.2).

Psychotherapeutic care in the treatment of patients with harmful use refers to: psychodiagnostic examination (clinical-psychological psychodiagnostic examination); individual, group, and family psychotherapy; individual, group, and family psychological counseling (individual clinical-psychological counseling; group clinical-psychological counseling; family clinical-psychological counseling); psychocorrectional work (individual clinical-psychological correction; group clinical-psychological correction) and cognitive rehabilitation (CR) (clinical-psychological training; social-rehabilitation work; clinical-psychological milieu therapy); training in mindfulness techniques and relaxation techniques (procedures for adaptation to microenvironment conditions; procedures for adaptation to macroenvironment conditions) (Appendix A3.3). At the same time, brief psychotherapeutic interventions (brief interventions – BI) form the basis of psychotherapy for harmful use [84–91]. As indicated (presence of co-occurring mental and behavioral disorders that impede abandonment of harmful psychoactive substance use) and upon the patient's relevant request, extended psychotherapeutic care can be provided.

Psychotherapeutic care is provided in individual, paired (family work), and group formats (Appendix A3.4), which have comparable efficacy in the treatment of addictive disorders (including harmful use) and similar nonspecific factors of change [92; 93; 94].

Psychotherapeutic care for patients with harmful use can be provided by a psychotherapist, a psychiatrist-narcologist, or a medical psychologist under the supervision of a psychotherapist (Appendix A3.5). Social work specialists, social workers, and chemical dependency counselors also participate in organizing and conducting psychotherapeutic measures under the supervision of a physician (Appendix A3.5).

Comments: It is suggested to conduct from 2 to 15 sessions of psychotherapy aimed at preventing and/or correcting the harmful use of psychoactive substances. The specified number of sessions includes:

• 1–3 sessions of psychotherapy focused on enhancing motivation for the ongoing psychotherapy and pharmacotherapy of the consequences of harmful use; and

• 1–3 sessions of psychotherapy focused on enhancing compliance with the ongoing psychotherapy and pharmacotherapy of the consequences of harmful use; and/or

• 1–3 sessions of personality-oriented psychotherapy to correct the main personality factors of harmful use; and/or

• 1–3 sessions of psychotherapy focused on developing skills in emotional self-regulation, relaxation, and stress coping; and/or

• 1–3 sessions of psychotherapy to develop self-control skills and voluntary inhibition of impulsive behavior.

The total duration of psychotherapy depends on the chosen method; the level of proficiency of the specialist providing psychotherapeutic care in specific psychotherapy methods; the individual characteristics of the patient; and the goals and objectives of psychotherapy.

Comments: The consequences of harmful use of psychoactive substances include a number of serious somatic diseases, including: injuries, acute poisoning, aspiration pneumonia, esophagitis, gastritis, pancreatitis, cardiac arrhythmia, cerebrovascular disorders, myopathy, rhabdomyolysis, liver diseases (hepatitis, fatty liver disease, cirrhosis), peripheral neuropathy, encephalopathy, osteoporosis, skin diseases, hypertension, sexual dysfunction, sepsis, viral hepatitis (B and C), HIV infection, etc. Treatment for these conditions requires continuous medication intake, however, the treatment regimen is often violated by psychoactive substance users, which leads to the aggravation of existing disorders.

Comments: The duration of psychotherapy depends on the chosen method, the characteristics of the patient's family system, the presence of relatives at risk for developing harmful use, and the goals and objectives of psychotherapy.

Comments: These factors include the therapeutic alliance; empathy, congruence, and unconditional positive regard from the specialist; feedback (to and from the patient); expectancy effects; and group cohesion (in the case of group-based work). See Appendix A3.2.

Comments: Building a therapeutic alliance in the treatment of patients with harmful use is an important, but not a priority task, since the short-term format of harmful use treatment may hinder the establishment of high-quality, long-term therapeutic relationships. See Appendix A3.2.

Comments: a deficit of empathy and a highly confrontational style lead to iatrogenic effects of psychotherapy and a decrease in compliance among patients with harmful use.

Comments: For screening recommendations, see the section below: "Recommendations for the organization of the psychotherapeutic process in the treatment of harmful use: psychoeducational and psychodiagnostic assessment".

3.2.1 Psychodiagnostic assessment

Comments:

The preliminary diagnostic assessment includes screening for psychoactive substance use using validated psychometric tools; evaluation of laboratory test results; conducting anamnestic, clinical-diagnostic, and motivational interviewing (MI) with the patient and their relatives (if necessary and with the patient's consent) [80; 177]; and reviewing available medical documentation to gather information on:

1. History of the disease:

   • History of psychoactive substance use; consequences for mental, familial, and social functioning;

   • General medical and psychiatric examination (history of previous hospitalizations and treatment outcomes);

   • Family and social history;

   • Presence of comorbid somatic, mental, and addictive disorders.

2. The level of development and functioning of various psychological and social functions, if necessary using standardized tools [1; 178–180]:

   • Cognitive functions (memory, attention, etc.);

   • Emotional states (anxiety level, depression, etc.);

   • Motivation (stage of readiness to change, compliance, etc.);

   • Autoaggression (suicidal risk, non-suicidal self-injury, etc.);

   • Interpersonal relationships (attachment style, family system, ability to form a therapeutic alliance, etc.).

Comments: The AUDIT and DUDIT tests can be used for this purpose (Appendix G1 and G2).

Comments: Assessment of the level of motivation for treatment and readiness to change is based on data from the MI conducted with the patient, as well as standardized questionnaires, for example, the Stages of Change Readiness and Treatment Eagerness Scale "SOCRATES" (Appendix G3) [190; 191].

Comments: The assessment involves identifying various types of personal organization in patients with substance use disorders (latent character accentuations [personality styles], character accentuations, personality disorders) in order to specify person-centered psychotherapy targets and develop a clearer treatment plan. In addition to clinical diagnostic interviews, various standard psychodiagnostic tools can be used if necessary [199-203], etc.

Comments: assessment of suicidal risk and typical forms of autoaggressive behavior can be carried out using semi-structured suicide interviews [210] and standardized suicidal risk questionnaires (see review [211]).

Comments: The assessment includes diagnosing the level of the formed therapeutic alliance and adherence to pharmacotherapy for harmful consequences of psychoactive substance use, especially severe chronic diseases such as viral hepatitis and human immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS). The level of adherence to abstaining from psychoactive substances is measured using objective means (laboratory tests for psychoactive substances in the patient's body); pharmacological adherence is also measured using standardized tools [219].

3.2.2 Planning of non-pharmacological treatment

Comments: Drawing up an individual psychotherapeutic program involves selecting and adapting psychotherapy methods to provide the most effective assistance to patients with substance use. When selecting psychotherapy methods for inclusion in the individual program, 4 main types of factors are taken into account:

1. Patient factors:

   • Medical diagnosis and disease severity;

   • Stage of readiness to change at which the patient is located;

   • Individual capabilities and personality traits (age, gender, education, intelligence, cognitive features, capacity for creative thinking and reflection, personality traits, intrapersonal pace of mental processes, etc.; presence of a support system);

   • Individual preferences and values (the patient's ability to accept a particular psychotherapeutic concept).

2. Goal-setting factors (targets, goals, and objectives of psychotherapy).

3. Professional preferences and education of the psychotherapist.

4. Organizational factors (related to the organization providing psychotherapeutic services, e.g., availability of computerized cognitive training tools, well-being of organizational functioning, the organization's ability to ensure a therapeutic environment).

Thus, the psychotherapy method is chosen based on its potential suitability for a particular patient, as well as the professional training of the physician, and the recommendation grade is relatively conventional, serving as an indicator that the specified type of psychotherapy belongs to professional, ethical, and effective psychotherapeutic methods (Appendix A3.6). The specialist conducting the psychotherapy may use both primary and auxiliary psychotherapy methods and the psychotherapeutic techniques developed within them, if he/she possesses the appropriate qualification and the logic of the psychotherapeutic process and the patient's condition require it.

Comments: compared to the individual psychotherapeutic program, the psychotherapy plan is a narrower, more specific plan for implementing a certain psychotherapeutic intervention aimed at addressing a limited number of goals and objectives formulated in the individual program. The psychotherapy plan is structured taking into account the same factors as when building the individual program and can be adjusted during the psychotherapy process.

Comments: Determining the stage of change at which the patient is located is necessary to avoid negative effects of psychotherapy (e.g., premature termination of treatment, acting out, intensification of dysphoric disorders, etc.) due to untimely corrective intervention by the specialist. Mismatch between treatment and the stage of change of patients leads to a 45% dropout rate from therapeutic programs [238]. For interventions depending on the stage of readiness to change, see Appendix A3.7.

Comments: In the treatment of patients with substance use, two types of psychotherapy goals are generally distinguished: achieving complete cessation of psychoactive substance use and achieving controlled use. Although achieving complete sobriety is the main strategic goal of treatment for substance use, controlled use can be a motivational goal in the initial stages of psychotherapy in patients with low motivation for treatment or a persistent mindset toward achieving controlled use, confrontation of which may lead patients to drop out of the treatment program. Nevertheless, in cases of severe somatic pathology or conditions that imply the complete exclusion of psychoactive substance consumption (pregnancy, lactation, preoperative preparation), the goal of psychotherapy is exclusively the cessation of psychoactive substance use.

Comments: Voluntariness is one of the fundamental principles of psychotherapeutic treatment. Despite the mandatory documented consent for medical treatment, which also includes psychotherapeutic services, a psychotherapeutic contract must be concluded with the patient for the implementation of said intervention prior to conducting any psychotherapeutic procedures within the framework of the psychotherapeutic process. The conclusion of a psychotherapeutic contract is a psychotherapeutic intervention in its own right. An oral contract is usually sufficient; however, in certain cases (antisuicidal, antipsychotic, behavioral contract regarding medication intake, etc.), a written contract drawn up jointly by the patient and the physician may be required. The main types of contracts and the principles of drafting behavioral contracts are briefly described in Appendix A3.8.

3.2.3 Selection of non-pharmacological treatment methods

Comments: despite the large number of existing empirically substantiated psychotherapeutic methods and their approximately equal effectiveness in the treatment of addictive disorders, the optimal approach in the therapy of harmful use is to use one or more of the psychotherapeutic and/or psychological counseling methods recommended below in short-term (1–12 sessions) and medium-term formats (12–24 sessions):

• Motivational interviewing (MI) and motivational psychotherapy (MP) (from 1 to 12 sessions); and

• Cognitive behavioral therapy (CBT) (at least 3 sessions); and/or

• Behavioral skills training (at least 1–3 sessions); and/or

• Mindfulness skills training (at least 1–3 sessions); and/or

• Self-control skills training (at least 1–3 sessions).

If necessary, or at the request of the patient and/or their relatives, family counseling and/or psychotherapy may be added to the aforementioned methods.

For a general list of basic and auxiliary methods with empirically proven efficacy in the treatment of patients with harmful use, as well as their brief description, see Appendices A3.6 and A3.9–A3.12.

Comments: This intervention may pursue the following mutually complementary goals:

1. Psychodiagnostic assessment of the severity of psychoactive substance (PAS) abuse and harmful use;

2. Correction of PAS use with harmful consequences;

3. Formation of motivation to initiate treatment;

4. Enhancement of the patient's own motivation for treatment;

5. Enhancement of treatment motivation in relatives accompanying the patient who have been given the opportunity to attend the session (participate in a separate session) with the patient's permission.

The duration of the brief intervention depends on its type and the skills of the specialist providing it.

Brief interventions include elements of psychodiagnostics, motivational interviewing, and psychoeducation. The rationale behind brief interventions is that even if the percentage of individuals who change their substance use patterns after a single intervention is small, the public health contribution of a large number of primary care workers systematically performing this intervention is significant. For the types and proposed algorithm of brief interventions, see Appendix A3.9.

Comments: Elements of motivational interviewing are integrated into the psychodiagnostic session itself to stimulate the formation of a therapeutic alliance and obtain the maximum possible information provided by the patient in a collaborative spirit. Thus, at the initial stages (sessions 1–2), motivational interviewing is used for diagnostic purposes; to form or reinforce individual motivation for treatment; to strengthen the therapeutic alliance; and to formulate the initial psychotherapy plan. For a detailed description of motivational interviewing, see Appendices A3.6 and A3.9–A3.10.

Comments: Psychotherapy for patients with harmful use can be based solely on the application of motivational interviewing and motivational psychotherapy. If the specialist deems it necessary to use other psychotherapeutic methods, diagnostic sessions utilizing motivational interviewing are conducted at least once—in the middle of psychotherapy or closer to completion (the penultimate session). Based on the results of assessing changes in motivation levels and readiness for change, the psychotherapy plan and individual psychotherapy plan are adjusted.

Comments: The goals, objectives, and methods of CBT are determined in accordance with the needs of a specific patient. Indications for CBT in patients with harmful use include, but are not limited to, the following conditions:

• Pronounced cognitive deficits (thought distortions) leading to PAS use;

• Pronounced alexithymia;

• Deficits in social intelligence and empathy;

• Pronounced anosognosia;

• Deficits in interpersonal communication skills;

• Deficits in stress-coping skills;

• Pronounced anxiety and/or depressive affect;

• Pronounced impulsive behavior;

• Low treatment compliance.

See more detailed information on CBT in Appendix A3.11.

Comments: The goals, objectives, and methods of skills training are determined in accordance with the needs of a specific patient. See more detailed information in Appendix A3.11.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

In most cases, rehabilitation of patients with harmful use of psychoactive substances is not carried out within the framework of specialized addiction medical treatment. In cases where medical rehabilitation is necessary, recommendations for its implementation are presented in the clinical guidelines for the treatment of mental and behavioral disorders caused by psychoactive substance use: dependence syndrome.

5. Prevention and Dispensary Observation

Dispenser observation (clinical follow-up) is carried out in accordance with the Procedure for Dispensary Observation of Persons with Mental Disorders and/or Behavioral Disorders Associated with the Use of Psychoactive Substances by a Psychiatrist-Narcologist (District Psychiatrist-Narcologist) (Order of the Russian Ministry of Health No. 1034 dated December 30, 2015 (registered with the Russian Ministry of Justice on March 22, 2016, No. 41495) "On Approval of the Procedure for Providing Medical Care in the Profile 'Psychiatry-Narcology' and the Procedure for Dispensary Observation of Persons with Mental Disorders and/s Behavioral Disorders Associated with the Use of Psychoactive Substances").

When harmful use is detected, secondary prevention becomes of paramount importance. It is predominantly medical and individual in nature, and is aimed at reducing the harmful consequences of PAS use and preventing the further development of PAS dependence syndrome.

6. Organization of Medical Care

Therapy can be carried out in outpatient and inpatient settings (including day care settings). In both inpatient and outpatient settings, the duration of treatment is determined individually.

As a rule, if the manifestations of harmful psychoactive substance use are mild, treatment can take place on an outpatient basis, especially if relatives are ready to help the person overcome this condition.

Indications for hospitalization:

1. Moderate or severe acute intoxication resulting from psychoactive substance use;

2. Unstable mental state of the patient (pronounced pathological craving for psychoactive substances);

3. Moderate and severe somatic disorders resulting from harmful psychoactive substance use;

4. Development of a psychotic state resulting from harmful psychoactive substance use.

Indications for discharge:

1. Relief of moderate or severe acute intoxication resulting from psychoactive substance use;

2. Stable mental state of the patient (cessation of pathological craving for psychoactive substances);

3. Relief of moderate and severe somatic disorders resulting from harmful psychoactive substance use;

4. Relief of a psychotic state resulting from harmful psychoactive substance use.

Patients diagnosed with harmful psychoactive substance use are recommended to receive specialized medical care in outpatient or day care settings if the patient's condition is assessed as mild.

If the patient's condition is assessed as moderate or severe, patients diagnosed with harmful psychoactive substance use are recommended to receive specialized medical care in inpatient settings. Inpatient medical care for the treatment of harmful substance use is provided when such use leads to intoxication, as well as moderate and severe somatic disorders (Appendix B).

7. Additional Information

Comments*: Supervision of the specialist treating a patient with harmful substance use, as well as participation in clinical case conferences, pursues the following goals:*

1. Ensuring the most effective care for the patient by clarifying difficulties that arose during psychotherapy;

2. Identifying the specialist's problems that impede effective patient treatment (countertransference reaction, differences in value orientations, etc.);

3. Prevention of professional burnout;

4. Professional development of the specialist.

The supervisor is either a more experienced colleague working in addiction psychotherapy and holding the appropriate qualification, or a professional supervisor holding the appropriate status that grants the right to provide supervision within the applied psychotherapeutic modality.

Comments: Training is conducted to acquire new competencies, maintain existing ones, and prevent professional deformation and "burnout".

Comments: the specialist records and describes the patient's mental status; the patient's current problems and requests that will be the subject of work in this psychotherapeutic session; the content of effective and ineffective psychotherapeutic interventions.

Comments: The specialist describes the preliminary plan of psychotherapeutic work, including long-term and short-term goals, tasks, and the initial psychotherapeutic contract. As psychotherapy progresses, the specialist makes changes to the initial plan and notes any changes in the psychotherapeutic contract.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Authors

1. Agibalova Tatiana Vasilyevna, Doctor of Medical Sciences. Association of Narcologists of Russia (Professional Community of Addiction Physicians). National Narcological Society. EATA (European Association for Transactional Analysis).

2. Buzik Oleg Zhanovich, Doctor of Medical Sciences, Association of Narcologists of Russia (Professional Community of Addiction Physicians).

3. Petukhov Aleksey Evgenyevich, Candidate of Pharmaceutical Sciences. Federation of Laboratory Medicine. Russian Narcological League.

4. Poplevchenkov Konstantin Nikolaevich, Candidate of Medical Sciences. Association of Narcologists of Russia (Professional Community of Addiction Physicians). National Narcological Society. Russian Society of Psychiatrists.

5. Tuchina Olga Dmitrievna, Psychologist, EATA (European Association for Transactional Analysis).

Working group members

Chair:

Krupitsky, Evgeny Mikhailovich, MD, Prof.

Secretary:

Gubanov, Georgy Alexandrovich

Working Group Members:

Agibalova, Tatyana Vasilyevna, MD

Arkus, Maxim Leonidovich, PhD

Bedina Inessa Aleksandrovna, Candidate of Medical Sciences

Buzik Oleg Zhanovich, Doctor of Medical Sciences

Vinnikova Maria Alekseevna, Doctor of Medical Sciences, Professor

Vyshinsky Konstantin Vitalievich, Candidate of Medical Sciences

Ilyuk Ruslan Dmitrievich, D.Sc. in Medicine

Kirzhanova Valentina Vasilievna, Doctor of Medical Sciences

Korchagina, Galina Alexandrovna, MD, Prof.

Lobacheva Anna Stanislavovna, Ph.D. in Medicine

Masyakin Anton Valerievich, Doctor of Medical Sciences

Mikhailov Mikhail Albertovich, Doctor of Medical Sciences

Nadezhdin Alexey Valentinovich, Ph.D. in Medicine

Nenastyeva Anna Yuryevna, Candidate of Medical Sciences

Poplevchenkov Konstantin Nikolaevich, Ph.D. in Medicine

Rybakova Ksenia Valeryevna, D.Sc. in Medicine

Utkin Sergey Ionovich, Candidate of Medical Sciences

Fadeeva Evgenia Vladimirovna, Candidate of Psychological Sciences

Shevtsova Yulia Bronyusovna, Candidate of Medical Sciences

Conflict of interest: none

All working group members confirmed the absence of financial support/conflict of interest that needs to be disclosed.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines:

1. Psychiatrist-narcologist

2. District psychiatrist-narcologist

3. Adolescent psychiatrist

4. Psychiatrist

5. District psychiatrist

6. Psychotherapist

7. Medical psychologist

The following information resources were used in the development of these clinical guidelines:

• Analysis of scientific literature sources and other data, as well as internet resources over the past 10 years:

• domestic: guidelines for physicians, scientific publications in periodicals, e-library scientific electronic library, State Register of Medicines, Register of Medicines, Federal State Statistics Service of the Russian Federation;

• foreign: Cochrane Library, Medline, MedScape, PubMed, National Institute on Alcohol Abuse and Alcoholism (NIAAA), Substance Abuse and Mental Health Services Administration (SAMHSA), European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)

• Regulatory documents of the Government of the Russian Federation and the Ministry of Health of the Russian Federation.

• During the development of these clinical guidelines, rating schemes were used to assess the level of certainty of evidence (1, 2, 3, 4, 5) (Appendix A2.1, A2.2) and the level of strength of recommendations (A, B, C) (Appendix A2.3, A2.4)

Appendix A2.1 - Scale for grading the levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Appendix A2.2 - Scale for grading the levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Appendix A2.3 - Scale for grading the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of substance use disorders (SUD), and in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Order of the Russian Ministry of Health No. 1034n dated December 30, 2015 (as amended on June 7, 2022) "On Approval of the Procedure for Providing Medical Care in the Profile 'Psychiatry-Narcology' and the Procedure for Dispensary Observation of Persons with Mental Disorders and (or) Behavioral Disorders Associated with the Use of Psychoactive Substances" (with amendments and additions that entered into force on August 1, 2022).

Order of the Russian Ministry of Health No. 103n dated February 28, 2019 (as amended on June 23, 2020) "On Approval of the Procedure and Deadlines for the Development of Clinical Guidelines, Their Revision, the Standard Form of Clinical Guidelines, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Guidelines" (with amendments and additions that entered into force on August 4, 2020).

Appendix A3.1. Targets of psychotherapeutic intervention

Table P5. Targets of psychotherapy

Appendix A3.2. Definition and evidence base for the use of non-specific factors in psychotherapy of patients using psychoactive substances with harmful consequences

Table P6. Use of non-specific psychotherapy factors

Appendix A3.3. Main interventions included in the non-pharmacological treatment block for harmful use

Table P7. Interventions included in the non-pharmacological treatment block for harmful use

Appendix A3.4. Forms of group work in psychotherapy

Group psychotherapy in addiction practice is understood as [72]:

• Psychoeducational groups (providing information on the harmful consequences of psychoactive substance use, comorbid diseases, etc.);

• Psychodiagnostic groups (short-term motivational and behavioral interventions; mental state monitoring, etc.);

• Cognitive-behavioral training groups (including skills training, emotional regulation and cognitive functions training, coping training);

• Proper psychotherapeutic groups (analysis of interpersonal interactions, group dynamics, individual work within the group to achieve individual treatment goals).

Group psychotherapy methods are most effective in working through problems of overcoming psychological defense, disease "denial", interpersonal interaction, and skills training.

Various group formats share a number of fundamental characteristics of the therapeutic process:

1. facilitation of emotional expression;

2. development of a sense of belonging to the group;

3. inevitability of self-disclosure;

4. testing new types of behavior;

5. use of interpersonal comparisons;

6. sharing leadership responsibility for the group with the facilitator. This is based on the opportunity for group interaction. When conducting the psychotherapeutic process in a group, the emphasis is placed on forming an emotionally intense and psychologically positive interaction among group members in order to correct their relationships and interactions with the microsocial environment

When organizing group work, it is necessary to remember that group therapy and counseling differ from self-help groups, first of all, by the presence of a clearly designated leader (a specialist with appropriate qualifications); the use of structured psychotherapeutic methods and techniques; the assessment of group dynamics and relationships; work in both current and historical perspectives; various group processes; individualization of therapy goals, etc.

Appendix A3.5. Labor functions of specialists participating in the organization and implementation of psychotherapeutic interventions

Table P8. Labor functions

Appendix A3.6. Methods with empirically proven efficacy recommended for use in psychotherapy for patients with harmful use of psychoactive substances

Empirically supported (evidence-based) clinical practice involves making informed treatment decisions based on knowledge of theoretical models and evidence-based treatment methods, combined with personal therapeutic experience and an understanding of the specific patient's characteristics. This means adapting psychotherapeutic recommendations to the patient's needs and the specifics of the medical organization providing treatment. The most common empirically supported psychotherapy methods for patients with substance use disorders are short-term behavioral and motivational interventions; motivational interviewing (MI) and motivational psychotherapy (MP); cognitive behavioral therapy (CBT) and CBT-based techniques (behavioral self-control training; «Moderate Drinking» methods [323], «Guided Self-Change» [324], «Seeking Safety» [325], behavioral couples therapy [326], and contingency management). Most of these types of psychotherapy are structured, short- to medium-term, and equipped with training manuals for clinicians.

Nevertheless, large meta-analyses have demonstrated approximately equal efficacy of professional psychotherapy methods in the treatment of various mental and behavioral disorders, including those caused by psychoactive substance use [124]. Therefore, the psychotherapist has relative freedom in choosing appropriate psychotherapeutic interventions. That is, methods of psychotherapy for treating substance use are chosen based on their potential suitability for a specific patient, as well as the physician's professional training. The level of recommendation evidence is relatively conventional, serving as an indicator that the specified type of psychotherapy belongs to professional, ethical, and effective psychotherapeutic methods. The psychotherapist may use both primary and auxiliary psychotherapy methods and the psychotherapeutic techniques developed within them, provided that he/she has the appropriate qualifications and it is required by the logic of the psychotherapeutic process and the patient's condition (Tab. P9).

Table P9. List of primary and auxiliary psychotherapy methods for patients with harmful use of psychoactive substances

Appendix A3.7. Transtheoretical model of stages of change

The transtheoretical model of change (stages of change independent of the psychotherapeutic theoretical modality) identifies the following patient process stages: precontemplation (resistance to change), contemplation, preparation, action, maintenance, and relapse (see Table P10) [327].

Table P10. Correspondence between patient treatment needs and stages of treatment

A limitation of the transtheoretical model of change is a certain determinism of relapse, which is viewed as a specific opportunity for testing coping strategies developed during treatment. Nevertheless, any analysis and correction are only possible if the patient resumes psychotherapy.

Appendix A3.8. Types of psychotherapeutic contracts

Adapted from [80].

Administrative contract: a contract outlining the external conditions for conducting psychotherapy: duration of the psychotherapy course, session length, format, payment, etc.

Therapeutic contract: a contract for achieving desired changes.

Behavioral contract has the following characteristics: (1) a specific form of contract (written or oral, negotiated or not, open or confidential); (2) contract participants (individual or unilateral; between two or more people—bilateral or trilateral); (3) behavior targeted for change; (4) consequences/outcomes (nature of consequences and means of achievement).

Contingency contract: a specific type of agreement providing for positive consequences or the delivery of positive reinforcing stimuli upon achieving desired behavior (or negative consequences upon demonstrating undesired behavior). These contracts describe the relative and absolute authority and obligations of each party regarding the achievement of a specific goal or task set through joint efforts.

Antabuse contract (disulfiram compliance contract) is a psychotherapeutic and counseling intervention aimed at encouraging regular intake of Antabuse (disulfiram), which induces nausea upon alcohol consumption and serves as an effective relapse prevention tool when taken consistently. The goal of the Antabuse contract is to ensure regular intake of Antabuse and reduce the number of alcohol-related conflicts between spouses, thereby decreasing the likelihood of disease relapse.

Three-party behavioral contracts aimed at establishing intra-family support for the patient's recovery process: (1) recovery contract (or sobriety contract); (2) substance use reduction contract; (3) continued recovery and relapse prevention plan.

Care contract is an agreement regarding the hospitalization of a suicide-risk patient or a patient in life-threatening intoxication.

Social control contract is an agreement on utilizing an external social support system to exercise additional control over problematic behavior.

Stop-contracts are contracts designed to prevent the most dangerous situations: anti-suicide, anti-psychotic, anti-homicide, and against "escaping" the psychotherapy process. Their implementation requires special competence from the psychotherapist.

Recommendations for drafting behavioral contracts:

1. The goal of change, determined jointly by the patient and the therapist through negotiation, must be clear and specific. The goal is framed in terms of desired behavior rather than behavior that needs to be stopped. For example, the contract states that "the patient attends all sessions" instead of a potential phrase that "the patient does not miss sessions";

2. It is necessary to detail the specific obligations (behavior) of each party to the contract required to achieve the goals, including timeframes or the frequency of demonstrating the required behavior;

3. The required target behavior must be observable, easily measurable, and recordable so that decisions regarding reinforcement can be made easily ("The patient speaks in a calm tone", "...addresses complaints to nurses rather than other patients", etc.);

4. The type of positive reinforcement the patient receives as a result of achieving a specific behavior must be clearly indicated. It is also necessary to specify the timeframe for delivering reinforcement (it is advisable to provide reinforcement immediately after the desired behavior is demonstrated or as soon as possible);

5. A detailed description of the consequences for failing to fulfill any contractual obligations by either party, including aversive consequences or sanctions.

6. A condition may be included regarding additional rewards provided to the patient if they achieve better results than planned by the contract;

7. Specific dates for the contract to enter into force, completion dates, and dates for renegotiation and renewal of contractual relations are included;

8. The contract must be signed by all parties.

Appendix A3.9. Short-term psychotherapeutic interventions

Brief intervention (BI) is a specific therapeutic strategy aimed at helping an individual stop or reduce (less frequently) psychoactive substance use. BI for substance use disorders is aimed at reducing substance consumption, mitigating the harm caused by habitual use, and preventing the development of substance dependence.

The pragmatic goal of BI can be either reducing consumption or achieving complete abstinence from psychoactive substances when mandated by significant reasons (pregnancy, medication intake). The clinician must be certain that they have done everything possible to motivate the patient toward complete abstinence at the stage of agreeing to a particular treatment option, and that the consumption of even "small doses" of substances in individuals with substance use disorders will not lead to catastrophic and irreversible consequences. The invitation to participate in substance reduction programs must be based on a thorough assessment of the patient's clinical and social capabilities, taking into account the core ethical requirement of "do no harm".

BIs are generally based on motivational interviewing techniques (FRAMES; DARES; SAOR (Support; Ask and assess; Offer assistance; Refer); BRENDA, etc.) and cognitive behavioral therapy (4 A’s (Ask, Assess, Assist, Arrange), BASICS (Brief Alcohol Screening for College Students), etc.). These are algorithmic procedures with a number of mandatory components [306 – 308]:

1. Screening of the subject's substance use (AUDIT tests, CAGE (Cut down, Annoyed, Guilty, Eye-opener), ASSIST (The Alcohol, Smoking and Substance Involvement Screening Test), MAST (Michigan Alcoholism Screening Test)); comparing this level with medical norms;

2. Psychoeducation: providing feedback on the negative effects of consumed substance doses;

3. Direct advice to stop/reduce substance use;

4. Planning for changes;

5. A follow-up telephone session after some time. Emphasis is placed on motivation to change substance-related behavior; increasing the patient's confidence in their ability to change behavior ("self-efficacy"); and social support for their efforts from a supportive specialist (and significant figures in the patient's environment) [329].

BI utilizes structured, short-duration therapy (typically 5–30 minutes). Following an assessment of the patient's substance use level, the patient is informed about the negative health consequences of excessive substance use; factors stimulating and inhibiting substance use are discussed; and factors promoting abstinence are explored.

Motivational interviewing (MI) is most frequently used as a BI. It is designed for working with patients exhibiting both harmful use and dependence on psychoactive substances at various stages of disease treatment, aimed at motivating the patient to quit substances, less frequently to reduce use, and to adhere to a particular treatment program. It is a prerequisite for achieving the effectiveness of subsequent therapeutic measures: pharmacotherapy, psychotherapy, and participation in medical and social rehabilitation programs (see Appendix A3.10). Short-term MI is conducted according to the following algorithms:

1. FRAMES:

   • Feedback – providing feedback;

   • Responsibility – fostering responsibility;

   • Advice – providing advice;

   • Menu – discussing the "menu" (treatment options);

   • Empathy – empathy;

   • Self-efficacy – fostering self-efficacy; or

2. DARES

   • Develop discrepancy – "Develop discrepancy";

   • Avoid argumentation – "Avoid argumentation";

   • Roll with resistance – "Roll with resistance";

   • Express empathy – "Express empathy";

   • Support Self-efficacy – "Support self-efficacy".

Additionally, the BRENDA psycho-corrective intervention is frequently used as a brief intervention [329; 330]. It is used in combination with pharmacotherapy. It can be administered by novice psychiatrists-narcologists and clinical psychologists, with an emphasis on treatment adherence. BRENDA time schedule: the first session is 30–40 minutes, subsequent sessions are 15–30 minutes. This intervention does not employ cognitive behavioral therapy strategies except in the interest of treatment adherence.

Approximate algorithm for conducting the BRENDA psycho-corrective intervention:

1. Assessment of all components of the patient's status—biological, mental, psychological, and social (B – Biopsychosocial evaluation).

2. Informing the patient about the results of their harmful substance use assessment based on specific rules: grounded in facts, non-moralizing or non-judgmental, avoiding confrontation and argument, and giving the patient sufficient time to process the evaluation (R – Report).

3. Empathy, compassion, and sympathy. Understanding the patient's problem, acknowledging and reflecting their emotional state. Collaboration rather than confrontation. Psychological support (E – Empathic understanding).

4. Analysis of the patient's current needs. Immediate needs, health, safety, etc. The patient's priorities in meeting their needs. The patient's needs reflect the interaction between the physician and the patient (N – Needs).

5. Direct instructions and advice from the specialist on how to meet the patient's current needs. Analysis of the patient's resources. Analysis of high-risk situations. Developing a strategy to achieve the patient's priorities (D – Direct advice).

6. Assessment of changes in the patient resulting from treatment advice and recommendations. Comprehensive dynamic analysis of biological, mental, psychological, and social indicators. Positive feedback (A – Assess reaction).

Recommended additional reading:

1. Agibalova T.V., Shustov D.I., Tuchina O.D., Mukhin A.A., Gurevich G.L. Alcohol reduction strategy as a new option in the treatment of alcohol dependence. Social and Clinical Psychiatry. 2015; 25 (3): 61-68.

2. Agibalova T.V., Tuchina O.D., Shustov D.I., Rychkova O.V. [Main methods of psychotherapy in addiction patients. Differentiated application of psychotherapeutic intervention]. National Guide to Addictology. Moscow: GEOTAR-Media; 2016. Chapter 10. p. 699-711. (In Russ.)

3. Krupitsky E.M. Short-term intensive psychotherapeutic intervention in addictology from the perspective of evidence-based medicine. Nevrologicheskiy vestnik. 2010;(3):25–27. (In Russ.)

4. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford Press; 2012.

5. Shustov D.I., Tuchina O.D. [Psychotherapy of alcohol dependence]. St. Petersburg: SpetsLit; 2016. 416 p. (In Russ.)

Appendix A3.10. Motivational interviewing and goals of motivational psychotherapy

A short-term, goal-oriented clinical method designed to enhance a patient's internal motivation to change through collaborative discussion of the problem, wherein ambivalence toward treatment is identified, explored, and resolved, and the patient's personal motivational processes facilitating change are defined. Special attention is paid to the verbal articulation of the problem to reveal the patient's ambivalence regarding treatment.

MI is designed to enhance an individual's intrinsic motivation and discuss the goals of behavioral change by identifying and exploring the patient's arguments in favor of change. MI is always aimed at forming, maintaining, and strengthening motivation for complete abstinence from psychoactive substances (PAS) through the gradual transition of the motivation for abstinence (verbal commitment to sobriety expressed by the patient under external pressure from family, work, etc.) into a true motive for abstinence as a need for a sober life. MI can be combined with any psychotherapeutic methods used in addictology. Furthermore, as a highly technological intervention, MI can be implemented at various stages of addiction treatment and repeatedly. MI is particularly effective in working with patients who have low motivation and treatment compliance.

MI and MP are based on the principles of C. Rogers' client-centered approach, the natural recovery concept, and the transtheoretical model of change.

Main components and techniques:

• Empathy;

• Alliance-building techniques;

• Feedback;

• Open-ended questions;

• Affirmations;

• Avoiding resistance;

• Working with ambivalence;

• Reflections;

• Summaries;

• Eliciting change talk;

• Change planning;

• Developing discrepancy;

• Cognitive dissonance.

The key concept is "readiness to change," which is viewed as the stage of motivation the patient is currently in—an internal state sensitive to external factors. Depending on the patient's stage of readiness to change, the goals of motivational interviewing vary, and the set of techniques used changes somewhat (Table S11).

Table S11. Modification of MI and MP goals depending on the stage of motivation

MI and MP increase treatment retention duration, reduce PAS use among adults and adolescents, decrease involvement in risk behaviors, and improve treatment adherence [99; 263]. Combining MI with other psychotherapeutic methods for addictive disorders (particularly CBT) significantly increased the efficacy of the latter [331]. However, there are mixed data regarding the efficacy of MI for preventing alcohol abuse in young adults [332]. MI serves as the foundation for a number of short-term anti-alcohol and anti-drug interventions (1–3 sessions lasting 15–30 minutes with possible follow-up telephone sessions), the efficacy of which in reducing and preventing PAS abuse often proves equivalent to or greater than medium-term forms of psychotherapy or traditional psychosocial interventions [333; 334]. Thus, MI is recommended for use in combination with other types of psychotherapy aimed at achieving lasting intrapersonal and ecological changes.

Recommended minimum: 1 to 3 psychotherapeutic sessions at the beginning of therapy, and as indicated throughout therapy.

Recommended additional reading:

1. Agibalova T.V., Rychkova O.V., Gurevich G.L., Kuznetsov A.G., Tuchin P.V., Valchuk D.S. [Psychotherapeutic approaches for opioid-dependent patients with low treatment motivation. Methodological recommendations for psychiatrists-narcologists, psychiatrists, psychotherapists, clinical psychologists, and social work specialists]. Federal State Institution National Research Center on Addictions of the Ministry of Health and Social Development of the Russian Federation; 2013. 32 p. (In Russ.)

2. Agibalova T.V., Rychkova O.V., Gurevich G.L., Kuznetsov A.G. [Application of compliance psychotherapy in the comprehensive treatment of alcohol-dependent patients. Methodological recommendations for psychiatrists-narcologists, psychiatrists, psychotherapists, and clinical psychologists]. Federal State Institution National Research Center on Addictions of the Ministry of Health and Social Development of the Russian Federation; 2012. 31 p. (In Russ.)

3. Agibalova T.V., Tuchina O.D., Shustov D.I., Rychkova O.V. [Main methods of psychotherapy in addiction patients. Differentiated application of psychotherapeutic intervention]. National Guide to Addictology. Moscow: GEOTAR-Media; 2016. Chapter 10. p. 699-711. (In Russ.)

4. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall; 1977.

5. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford Press; 2012.

6. Prochaska JO, Norcross JC, DiClemente CC. Changing for Good: A Revolutionary Program That Explores the Six Stages of Change and Teaches You How to Free Yourself from Bad Habits. New York: William Morrow; 1994.

7. Rogers C. The Art of Counseling and Therapy. Moscow: Aprel Press, Izdatelstvo Eksmo; 2002. 976 p. (In Russ.)

Appendix A3.11. Cognitive-behavioral approaches

CBT combines a number of treatment approaches based on social learning theories and the principles of operant conditioning [335]. The goal of CBT is to alter the learned association between PAS-associated stimuli and consumption using cognitive techniques and skills training [80]. The application of the method is based on the premise that emotions and behavior can be changed by influencing thought content; the possibility of such changes rests on the connection between the cognitive and emotional spheres. The CBT process aims to develop desired, adaptive forms of behavior based on learning theory principles. It is implied that behavioral change occurs through sequential stages: preliminary analysis of one's own behavior – action – decision – maintenance of changes and relapse prevention. The method is highly reproducible in clinical practice. Recommended minimum: 6 to 15 psychotherapeutic sessions.

In the treatment of addictive disorders, the main goals of CBT [276] are:

1. identifying intrapersonal and interpersonal factors ("triggers") that contribute to relapse:

   • awareness of emotions and underlying maladaptive decisions, pathological thinking patterns—dysfunctional beliefs, automatic thoughts activated in PAS use risk situations;

   • identifying and confronting thoughts about consumption;

2. coping skills training (including craving management);

3. PAS refusal skills training (including preparation for unforeseen situations);

4. functional analysis of PAS use (understanding what precedes use and its "positive" and negative consequences);

5. enhancing non-PAS-related activities.

Specific targets of CBT in addictology also include the treatment of comorbid disorders (e.g., affective disorders), and therapy for suicidal and auto-aggressive tendencies. In the latter case, CBT utilizes training and retraining to alter dysfunctional psychological patterns associated with auto-aggression: helplessness, hopelessness, inability to solve problems, perfectionism, irrational beliefs, and automatic thoughts, as well as altering the patient's view of suicide as an alternative to mental pain. The efficacy of CBT methods for treating various addictive disorders has been proven in numerous RCTs and demonstrated by a series of systematic reviews.

Relapse prevention training ("relapse prevention", relapse prevention therapy)

A cognitive-behavioral approach targeting the procedural nature of relapse as a stage in the natural change process, along with the development of coping strategies to maintain changes achieved during therapy [336]. Within relapse prevention therapy, based on the assessment of various relapse risk factors (physiological, interpersonal, intrapersonal, and environmental triggers), a unique profile of the patient's situations is created, and their ability to cope with them is assessed. Taking into account this profile and the patient's ability to control relapse triggers, specific strategies are utilized: training in new skills for coping with slips and the abstinence violation effect, and confronting positive expectancies regarding psychoactive substance (PAS) use. Global strategies are designed to address broader issues: balancing lifestyle and raising awareness of hidden relapse factors (overall stress level, use of rationalization and denial mechanisms, urge for immediate gratification, etc.). The main skill developed is forecasting the difficulties that a patient deciding to lead a sober lifestyle will face, and generating effective coping strategies.

Main components and techniques:

• Coping skills training;

• Confronting positive expectancies associated with PAS;

• Coping with slips;

• Assessing and emphasizing lifestyle balance;

• Coping with the desire to yield to the disease through other minor concessions;

• Coping with craving and urges to use;

• Addressing cognitive distortions.

A type of relapse prevention training is mindfulness-based relapse prevention (MBRP). Here, traditional relapse prevention is built on the use of Buddhist spiritual and meditative mindfulness practices [337]. These practices are used by patients (both during active therapy and as self-help) to improve awareness of external triggers and internal cognitive and affective processes, as well as to enhance the patient's ability to cope with complex cognitive, emotional, and physical experiences by observing these stressful or uncomfortable states (e.g., cravings), while avoiding habitual reaction patterns. This type of psychotherapy helps reduce craving levels and sensitivity to PAS-associated cues, contributing to a decrease in PAS consumption volumes [254].

Contingency management therapy

Contingency management (CM) therapy, or reinforcement-based motivation, is the closest to the behavioral tradition and is based on behavioral pharmacology and operant conditioning theory, according to which behaviors reinforced by positive consequences are repeated more frequently [335]. CM is a strategy to promote the maintenance of sobriety in patients by providing positive reinforcement (rewards) and withdrawing reinforcement or applying punitive measures (negative reinforcement) when patients exhibit undesirable behavior (using drugs or alcohol) [338]. It is based on behavioral pharmacology and operant conditioning theory, according to which behaviors reinforced by positive consequences are repeated more frequently [335].

Types of treatment related to CM are based on 3 main principles: (1) regular frequent monitoring of target behavior (urine drug screens for PAS several times a week); (2) delivery of tangible, positive reinforcing stimuli when the target behavior occurs (negative test results); and (3) withholding the reinforcing stimulus if the target behavior is not achieved (positive test results). CM is one of the most effective treatments for addictions because it not only helps reduce PAS consumption and increase remission rates, but also encourages other healthy behaviors: attending psychotherapy, prenatal consultations, using contraceptives, medication compliance, and retention in treatment programs [339 – 343].

Main components and techniques:

• Target behavior monitoring;

• Providing tangible, positive reinforcing stimuli for demonstrating target behavior;

• Withholding the reinforcing stimulus otherwise;

• Using behavioral contracts.

Self-control skills training

A multi-component behavioral intervention that builds skills for controlled PAS use, originally developed for individuals with harmful alcohol use and also used to achieve complete abstinence from PAS [344]. According to the self-control training (SCT) model, PAS misusers are capable of achieving the goal of moderate (controlled) use through the development of relevant skills and environmental modification.

Main components and techniques:

Self-monitoring of PAS use and urges to use;

Setting specific goals; differentiated control of PAS use and abstinence from drinking;

Entering into behavioral contracts specifying rewards and consequences for achieving the goal;

Identifying and managing triggers for heavy drinking; functional analysis of PAS-related behavior;

Relapse prevention training;

Motivation building;

Feedback.

SCT reduces the volume of PAS consumed (primarily alcohol) and the frequency of problems associated with PAS use; these effects persist for a long time (up to 2 years) and are as stable as those achieved through total-abstinence-oriented treatment, independent of the training method [290; 291]. However, it should be kept in mind that applying training focused on controlled use is contraindicated for patients with dependence syndrome [123].

Recommended reading:

1. Agibalova T.V., Goloshchapov I.V., Rychkova O.V. Compliance psychotherapy in patients with alcohol dependence. Narkologiya. 2010;3:58–64. (In Russ.)

2. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977.

3. Beck A.T., Freeman A. Cognitive Therapy of Personality Disorders. New York: Guilford Press, 1990.

4. Beck J.S. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York: Guilford Press, 2011.

5. Valentik Yu.V. Psychotherapy targets in addictology. In: Lectures on Addictology. Ed. by N.N. Ivanets. Moscow: Medpraktika; 2001. P. 233–243. (In Russ.)

6. Valentik Yu.V. Continual psychotherapy in patients with psychoactive substance dependence. In: Lectures on Addictology. Ed. by Prof. N.N. Ivanets. Moscow: Nolidzh; 2000. P. 341–364. (In Russ.)

7. Karvasarsky B.D. Psikhoterapiya: uchebnik dlya vuzov. St. Petersburg: Piter; 2002. 672 p. (In Russ.)

8. McMullin R.E. Handbook of Cognitive Therapy Techniques. New York: W.W. Norton & Company, 2000.

9. Moscow Psychotherapeutic Journal. Special issue on cognitive psychotherapy. Moscow, 1996;3. http://psyjournals.ru/mpj/1996/n3/

10. Moscow Psychotherapeutic Journal. Special issue on cognitive psychotherapy. Moscow, 2001;4. http://psyjournals.ru/mpj/2001/n4/

11. Feist J., Feist G.J., Roberts T. Theories of Personality. 8th ed. McGraw-Hill Education, 2013.

12. Kholmogorova A.B., Garanyan N.G. Cognitive-behavioral psychotherapy. In: Main Approaches to Modern Psychotherapy: Textbook. Ed. by Bokovikov A.M. Moscow: Kogito-Tsentr; 2000. P. 224–267. (In Russ.)

13. Shustov D.I., Tuchina O.D. [Psychotherapy of alcohol dependence]. St. Petersburg: SpetsLit; 2016. 416 p. (In Russ.)

14. Ellis A., Dryden W. The Practice of Rational Emotive Behavior Therapy. 2nd ed. New York: Springer Publishing Company, 2007.

Appendix A3.12. Family therapy

A group of methods where the object of psychotherapeutic intervention is the patient and their family environment. It can be delivered in group or individual formats. The main goal is the correction of pathological types of family relationships.

The goals of family therapy are:

1. psychoeducation—providing information on the harmful consequences of psychoactive substance use, the risk of developing dependence syndrome, treatment methods, and the role of relatives in maintaining the patient's sobriety and rehabilitation;

2. improving family functioning, primarily through:

   • correcting dependent-codependent relationships;

   • correcting negative cognitive and emotional states, including those caused by communication with the patient, and training relatives in coping methods (primarily using cognitive-behavioral therapy methods (see below in this section));

   • teaching methods for support and relapse prevention that can be used at home;

   • preventing the intergenerational transmission of PAS abuse within the family.

Specialists need to conduct 10 to 30 family counseling sessions involving at least one family member or significant other.

Family systems psychotherapy and genogram analysis. The family systems model is based on the premise that substance use is a core organizing factor within families. Adapting to substance use allows the family to maintain homeostasis: for example, a patient with alcohol dependence is unable to express feelings until they get intoxicated. Using a systems approach, the therapist identifies and attempts to modify maladaptive communication patterns or family role structures that utilize substance use to maintain stability [345].

Because psychological problems associated with substance use and cognitive (mnestic) deficits tend to be "transmitted" within families as biological or psychological artifacts [346–348], a tool has been developed in systems psychotherapy to track this transmission. Constructing genograms—visual representations of family history identifying which relatives/ancestors had similar disorders and psychosocial problems and when, and which social and family connections contribute to the patient's continued substance use [349]—can be used as an auxiliary tool for diagnosing and correcting family functioning, as well as preventing the intra-familial transmission of substance use disorders. Genograms promote awareness of the psychological nature of the disease and the contribution of the family and social environment to maintaining substance use-related or substance-induced disorders [350].

Family cognitive behavioral therapy is based on the premise that substance use is reinforced by interactions among family members. Behaviorally oriented treatment seeks to modify interactions and the target behaviors that trigger substance use in order to improve communication, problem-solving abilities, and coping skills. A particularly effective method of family cognitive behavioral therapy is the use of behavioral contracts, which are also developed in transactional analysis. Contracts can be categorized into types such as: contingency contracts (reward-motivated); continued recovery contracts and relapse prevention plans; sobriety contracts; substance use reduction contracts; self-care skills training contracts, etc.

Other family CBT techniques: the "alcohol-focused spouse involvement" method; self-control training and coping skills training for alcohol-related situations; elements of reward motivation; confessional/trust-building talks; relapse prevention training; problem-solving techniques. The application of family psychotherapy in addiction patients helps resolve a primary objective: integrating the concept of addiction disorders specifically as medical disorders rather than moral, psychological, or other individual notions about the nature of substance use. Essentially, family psychotherapy consists of overcoming the relatives' anosognosia and establishing a constructive alliance between all family members and the physician to develop coping strategies for the disease. Many family members experience anticipatory anxiety regarding the patient's discharge from the hospital, directly related to the destructive behavior they observed prior to hospitalization and the start of therapy. Therefore, it is necessary to systematically reassure the patient's relatives and social circle (neighbors, acquaintances) that the patient does not pose a danger provided they maintain sobriety. Family psychotherapy also includes legal counseling, resolution of family conflicts, and assistance with household matters (carried out by a social worker).

Family therapy helps reduce substance use; establish long-term remissions; improve relationships among family members; and improve the psychological well-being of children within families.

Recommended reading:

1. Moskalenko V.D. Dependence: A Family Disease. Moscow: Institute of Counseling and Systemic Solutions, 2015. 368 p.

2. Methodological recommendations on the specialization of psychiatry-narcology for clinical residents, postgraduate students, and psychiatrists-narcologists. Section "Chemical Addictions and the Family". Part 1 / Compiled by V.D. Moskalenko. Moscow, 2014. 59 p.

3. Methodological recommendations on the specialization of psychiatry-narcology for clinical residents, postgraduate students, and psychiatrists-narcologists. Section "Chemical Addictions and the Family". Part 2 / Compiled by V.D. Moskalenko. Moscow, 2014. 79 p.

Appendix A3.13. Differential diagnosis of harmful use and dependence

Table P12. Differential Diagnosis

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

F1x.1xx HARMFUL USE OF PSYCHOACTIVE SUBSTANCES. USE OF PSYCHOACTIVE SUBSTANCES WITH HARMFUL CONSEQUENCES.

Harmful use of a psychoactive substance (substance use) is a pattern of alcohol or drug use that causes damage to health. This damage can be physical (e.g., hepatitis virus transmission through intravenous drug use) and/or psychological (development of depression after alcohol use).

Harmful substance use is not yet dependence (with all its manifestations), but neither is it normal. The boundaries between substance dependence and harmful use are often blurred, and making a correct diagnosis can be challenging. The development of substance dependence occurs gradually, depending on the individual characteristics of a particular organism. Genetic factors, environmental influences, and personality traits all play a role here.

Upon first trying any substance, most people do not immediately experience positive sensations; a normal "protective reaction" occurs in the form of nausea, vomiting, headaches, etc. Subsequently, some people, having experienced negative emotions, abandon substance use altogether, while others continue experimenting, including with different substances. Some individuals immediately experience positive sensations from the first doses of a substance. On the other hand, even a single instance of alcohol or drug use can cause significant harm to the body. For example, severe acute poisoning can occur, potentially leading to a comatose state.

Attention must be paid to a number of signs that may indicate the onset of dependence. These include the loss of "protective reactions" to substance intake, loss of quantitative control, an increase in the dose required to achieve positive effects, more frequent substance use, the emergence of obsessive thoughts about substance use, and using substances not for pleasure, but despite negative consequences (disruption of friendships, family, and employment relationships, legal problems, deteriorating health, agonizing hangover states). If these signs are detected, one should consult a specialist. Adolescent alcohol use is also a reason to consult a physician. If instances of drug use occur, this in itself may warrant consulting specialists.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

G1. Alcohol Use Disorders Identification Test in the Russian Federation (RUS-AUDIT)

Russian title: RUS-AUDIT Test for identifying alcohol use disorders.

Original title: The Russian Alcohol Use Disorders Identification Test (RUS-AUDIT)

Source: RUS-AUDIT validation study protocol. Adaptation and validation of the AUDIT (Alcohol Use Disorders Identification Test) for detecting alcohol use disorders in the Russian Federation. Copenhagen: WHO Regional Office for Europe; 2021. URL: https://who-sandbox.squiz.cloud/ru/health-topics/disease-prevention/alcohol-use/publications/2021/the-rus-audit-validation-study-protocol-adapting-and-validating-the-alcohol-use-disorders-identification-test-audit-in-the-russian-federation-2021

Type (underline): rating scale; index; questionnaire; other (specify): screening test.

Purpose: A test to identify individuals with hazardous and harmful alcohol consumption patterns. This screening test allows physicians to determine the severity of alcohol abuse and dependence.

Content (template):

Please select the response number that best applies to you based on the table.

Check the answer that applies to you (numbers in cells = scores).

ALCOHOL UNITS BY TYPE OF BEVERAGE

Notes: According to the WHO, the minimum standard unit of pure alcohol is 10 grams of ethanol.

Interpretation of the RUS-AUDIT test for men and women

G2. Drug Use Disorders Identification Test (DUDIT)

Russian title: Drug Use Disorders Identification Test (DUDIT).

Original title: The Drug Use Disorders Identification Test (DUDIT)

Source: Berman A.H., Bergman H., Schlyter F. DUDIT (The Drug Use Disorders Identification Test) Manual Version 1.0. Stockholm: Karolinska Institutet Center for Psychiatric Research; 2005. 12 p. URL: https://www.euda.europa.eu/drugs-library/drug-use-disorders-identification-test-dudit_en

Type (underline): rating scale; index; questionnaire; other (specify): screening test.

Purpose: A test to identify individuals with hazardous and harmful drug use patterns.

Content (template):

You are asked to answer several questions about drugs. Please answer as accurately and honestly as possible by selecting the option that best applies to you.

Key (interpretation):

Questions 1-9: 0, 1, 2, 3, 4 points for response options 1 through 5, respectively.

Questions 10-11: 0, 2, 4 points for response options 1 through 3, respectively.

Sum all points. Maximum score is 44 points.

• 6 or more points for men; 2 or more points for women – zone of harmful drug use;

• 25 points or more – high probability of drug dependence syndrome.

Notes: The indicated scores are preliminary data; additional information is required to diagnose harmful use or dependence.

G3. Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

Russian title: SOCRATES (Stages of Change Readiness and Treatment Eagerness Scale)

Original title: Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

Source: Miller W.R., Tonigan J.S. Assessing drinkers' motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors. 1996; №10: 81–89. URL: https://www.drugsandalcohol.ie/26826/

Russian adaptation: Klimanova S.G., Trusova A.V., Kiselev A.S., Berntsev V.A., Gromyko D.I., Ilyuk R.D., Krupitsky E.M. Adaptation of the Russian-language version of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) // Counseling Psychology and Psychotherapy. 2018; № 26(3): 80—104. URL: https://psyjournals.ru/files/95217/cpp_2018_n3_Klimanova_Trusova_et_al.pdf

Type (underline): rating scale; index; questionnaire; other (specify): structured self-administered patient questionnaire.

Purpose: A test to assess motivation for behavior change related to substance abuse.

Content (template):

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) (adapted version, see above)

Patient name: Patient ID: Date:

Instructions. Please read each of the statements below carefully. Each statement describes something you might or might not think about your alcohol/drug use. For each statement, circle one of the numbers on the scale to the right to indicate how much you agree or disagree with the statement at the present time. Please circle only one number for each statement.

The template combines test versions for alcohol and substance use. When testing, patients should be offered a form with one of the italicized options—that is, if alcohol harmful use is suspected, leave only "alcohol" from the "alcohol/drugs" pair.

Scoring: 1 point – "Strongly disagree"; 2 points – "Disagree"; 3 points – "Undecided"; 4 points – "Agree"; 5 points – "Strongly agree". The total score is summed, and readiness-for-change indicators are evaluated using the table below [191].

Test norms of the "Readiness to Change" questionnaire (raw score to sten conversion table)