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Treating Drug Dependence
Chapter 18

Treatment of Addiction

  • Individuals who are addicted to drugs come from all walks of life.
  • Many suffer from occupational, social, psychiatric or other medical problems that can make their addictions difficult to treat.
  • The severity of addictions varies widely. It is essential to match treatment with the needs of the client.

Data from American Psychiatric Association, DSM-5 Implementation and Support, 2013. Available http://www.dsm5.org/Pages/Default.aspx; American Psychiatric Association, Substance-Related and Addictive Disorders, 2013. Available http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20Sheet.pdf; and Insel, T. Director’s Blog: Transforming, 2013. Diagnosis Available http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

Drug Addiction Treatment in the United States

  • According to SAMSHA, in 2011, 21.6 million persons needed treatment for an illicit drug or alcohol use problem.
  • However, in 2011, only 2.3 million persons received treatment at a specialty facility

Treatment for what?

  • In 2006, 4.0 million persons received treatment for a substance use problem
  • 2.5 million claimed alcohol as their main problem
  • 1.2 million persons received treatment for marijuana
  • 928,000 persons for cocaine,
  • 547,000 for pain relievers,
  • 535,000 for stimulants,
  • 466,000 for heroin, and
  • 442,000 for hallucinogens.
  • (Note that respondents could indicate that they received treatment for more than one substance during their most recent treatment

Need for Treatment and Denial

Of the 21.1 million people in 2006 who were classified as needing substance use treatment but did not receive treatment at a specialty facility in the past year,

940,000 persons (4.5 %) reported that they felt they needed treatment for their illicit drug or alcohol use problem.

Of these 940,000 persons who felt they needed treatment,

314,000 (33.5 %) reported that they made an effort to get treatment

625,000 (66.5 %) reported making no effort to get treatment.

Treatment of Addiction (continued)

  • It is valuable to intervene at the earliest possible stage of addiction with the least restrictive form of appropriate treatment.
  • It is important that treatment providers determine the severity of addiction as well as the readiness of an individual to change his or her behavior.

Assessing Addiction Severity and Readiness to Change

  • Addiction Severity Index (ASI): Among the most widely used assessment instruments in the field.
  • The ASI focuses on possible problems in six areas: medical status, employment and support, alcohol and drug use, legal status, family and social relationships, and psychiatric status.
  • The ASI provides information that can be used to identify and prioritize which problem areas are most significant and require prompt attention.

Maslow’s Hierarchy of Needs

  • Includes food, drink, warmth, sleep, and shelter.
  • Can be extended to problems including unidentified or inappropriately managed health problems, medication adherence issues, and physical alterations due to drug and/or alcohol dependence.
  • Once fundamental needs are addressed, a second level of needs involving security and safety can be addressed including such issues as stability, order, law, and limits.
  • Precontemplation (unaware of problem)
  • Contemplation (problem may exist)
  • Preparation (decision to change)
  • Action (active steps to change)
  • Maintenance (keeping all the progress gained in treatment)

Stages of Change
Change is a multi stage process

  • Attain and Maintain abstinence from the drug or behavior
  • Develop a personally meaningful lifestyle
  • Functioning in family
  • Workplace
  • Society

Goals of Treatment

Principles of Treatment

  • Variety of approaches to treating addiction
  • Behavioral therapy
  • Counseling
  • Psychotherapy
  • Cognitive therapy
  • Pharmacological

therapy

  • Successful programs often combine therapies

Principles of Treatment (continued)

  • Many who enter treatment drop out before receiving all of its benefits.
  • Successful treatment often requires more than one treatment exposure.
  • Relapse rates for addiction resemble those of other chronic diseases, such as diabetes, hypertension, and asthma.

Figure 18.01: Relapse rates for addiction resemble those of other chronic diseases such as asthma, diabetes, and hypertension.

Reproduced from National Institute on Drug Abuse (NIDA). Principles of Drug Addiction Treatment. Pub. No. 12-4180. Washington, DC: National Institutes of Health, April 2012.

NIDA’s Principles of Drug Treatment

  • Addiction is a complex but treatable disease that affects brain function and behavior.
  • No single treatment is appropriate for all individuals.
  • Treatment needs to be readily available.
  • Effective treatment attends to multiple needs of the individual, not just to his/her drug use.
  • Remaining in treatment for an adequate period is critical.
  • Behavioral therapies are the most commonly used forms of drug abuse treatment.

NIDA’s Principles of Drug Treatment (continued)

  • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
  • An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
  • Many drug-addicted individuals also have other mental disorders.
  • Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
  • Treatment does not need to be voluntary to be effective.
  • Drug use during treatment must be monitored continuously, as lapses during treatment do occur.
  • Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

NIDA’s Principles of Drug Treatment (continued)

Figure 18.02: Reasons for not receiving substance use treatment among persons aged 12 or older who needed and made an effort to get treatment but did not receive treatment and felt they needed treatment: 2008-2011.

Reproduced from Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2011 National Survey on Drug Use and Health: Volume I. Summary of National Findings. NSDUH Series H-44, HHS Publication No. SMA 12-4713. Rockville, MD: SAMHSA, 2012.

  • The age of the abuser is an important consideration when designing treatment, including both the age of exposure to drugs and the age at which treatment is initiated.
  • From birth through early adulthood, the brain undergoes a prolonged process of development during which a behavioral shift occurs such that actions go from being more impulsive to more reflective and reasoned.

Other Important Considerations

  • The brain areas most closely associated with judgment, decision-making, and self-control undergo a period of rapid development during adolescence.
  • Treatment should attend not only to biological distinctions between genders but also to the social and environmental factors that can differentially influence motivations for drug use, treatments that are most effective, reasons for seeking treatment, types of environments where treatment is obtained, and consequences of not receiving treatment.

Other Important Considerations

  • Gender-related considerations in the treatment of substance abuse are of importance.
  • Criminal justice-involved substance abusers are another population that often benefits from specialized treatment approaches.
  • Therapeutic work environments that provide employment for abstinent drug-abusing individuals promote a continued drug-free lifestyle.

Other Important Considerations

  • Several factors influence retention in treatment programs, including individual motivation to change drug-using behavior and degree of support from family and friends.
  • Pressure from employers, the criminal justice system, and/or extensions of the court (i.e., child protective services) can be important.

Other Important Considerations

Comorbidity

  • A condition where two or more illnesses occur in the same person, simultaneously or sequentially.
  • Comorbidity also suggests interactions between the illnesses that affect the course and prognosis of both.

Comorbidity (continued)

  • Comorbidity between drug addiction and other mental illnesses is common.
  • Mental illnesses can sometimes lead to substance abuse and addiction in that individuals sometimes abuse drugs to self-medicate an underlying medical condition.

Comorbidity (continued)

  • The high incidence of co-morbidity between substance abuse disorders and other mental illnesses does not mean that one necessarily caused the other.
  • Effective treatment of individuals with co-morbid substance abuse and mental illnesses requires accurate diagnosis of both conditions.

Comorbidity (continued)

  • Several fundamental barriers impede treatment of co-morbid disorders.
  • Often, one professional background is broad enough to address the full range of problems presented by patients.
  • A bias exists in some substance abuse treatment facilities against using any pharmacological intervention, including those necessary to treat serious mental illnesses, such as depression.

Reported Reasons Treatment Not Obtained

  • Lack of health coverage and could not afford cost.
  • A lack of readiness to stop using
  • A possible negative effect on job
  • Persons had health coverage but did not cover treatment or did not cover cost
  • A lack of transportation or inconvenience
  • Persons did not know where to go for treatment
  • Perception that it might cause neighbors/community to have negative opinion
  • A lack of time for treatment

Important Consideration

  • Research has demonstrated that treatment is far less expensive than simply incarcerating addicts.

Mental Health Parity and Addiction Equity Act

  • Requires group health insurance plans (involving greater than 50 insured employees) that offer coverage for mental illness and substance use disorders to provide those benefits in a no more restrictive manner than all other medical/surgical procedures covered by the plan.
  • Abstinence
  • Structured Recovery Program
  • Repair of Biopsychosocial Damage
  • Physical
  • Psychological
  • Family
  • Community

Treatment Program Context

  • Detoxification
  • Active Treatment
  • Aftercare = Relapse Prevention
  • Medically assisted aftercare
  • Methadone maintenance, antabuse (disulfiram), nicotine patches

Treatment Stages

  • Out patient
  • Education
  • Group/Individual/Family
  • Inpatient/Residential
  • Hospital
  • Prison

Treatment Types

  • Outpatient – can the person function out on their own? Clinic services range from drop-in counseling to formal counseling to vocational counseling.

  • Inpatient— medical hospital or residential model - very structured environment

Treatment

Historic Approaches to Treatment

  • Alcoholics Anonymous
  • Open vs. Closed Meetings
  • Al-Anon, Alateen
  • Minnesota Model

Figure 18.CO

© vm/iStockphoto.com

  • 1935
  • 12 Steps and 12 Traditions
  • Helped the most get sober
  • Basis for other recovery programs:narcotics anonymous, cocaine anonymous, overeaters, debtors, sex addicts, gambling, cyber addicts, fundamentalists, etc.
  • Also the basis for family and friends: Al-Anon, Cocaine Anon, Nar-Anon, S-Anon etc.

Alcoholics Anonymous

Alcoholics Anonymousｨ is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for AA membership; we are self-supporting through our own contributions. AA is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy, neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.

www.alcoholics-anonymous.org

  • Alcoholics Anonymous Website
  • http://www.aa.org/
  • 12 step blog and online meetings
  • www.12stepforums.net/
  • http://www.step12.com/oregon.html

12 Step sites

General Therapeutic Strategies

  • Some are individualized and some are group-based.
  • Not all treatment programs fit perfectly into any one category
  • Include short-term inpatient, long-term inpatient and outpatient therapy

Medical Detoxification

  • The process of safely managing the acute physical symptoms of withdrawal associated with stopping drug use
  • Medications including benzodiazepines and other sedatives are often utilized
  • Can be medically necessary because untreated withdrawal from some agents can be fatal.
  • Although sometimes referred to as a distinct treatment modality, it is more appropriately considered a precursor to treatment

Therapeutic Communities (TCs)

  • The best-known residential treatment model
  • Focus on the “resocialization” of the individual and use the program’s entire community (e.g., staff, other residents) as important treatment components
  • Planned lengths of stay in TCs are often between 6 and 12 months.
  • TCs often offer comprehensive services, which can include employment training on site.

Figure 18.UN03: A patient recieves individual counseling in an alcoholism treatment center.

© mangostock/Shutterstock, Inc.

Behavioral Therapies

  • Cognitive Behavioral Therapy
  • Contingency Management (CM) Interventions/Motivational Incentives
  • Community Reinforcement Approach (CRA) Plus Vouchers
  • Motivational Enhancement Therapy (MET)
  • The Matrix Model
  • 12-Step Facilitation
  • The most effective treatment programs recognize that most appropriate goal for the treatment of substance dependence is the development of a personally meaningful lifestyle that involves productive functioning in the family, workplace, and society. This typically involves:

Treatment Goals

  • Abstinence from alcohol and other mind altering drugs. (At certain stages in the recovery process abstinence may not be realistically possible. At those times, effective programs provide harm reduction and motivational counseling processes can then be used to prepare the client to accept the goal of abstinence.)

Abstinence

  • A Structured Recovery Program: The development of a structured recovery program that supports abstinence and the development of a lifestyle centered around sober and responsible activities.

Structured Recovery

  • Repair of Biopsychosocial Damage: Repair of the physical, psychological, and damage caused by the substance use disorder.

Treatment Goals

  • Treatment of Coexisting Disorders: The treatment of coexisting mental and personality disorders that interfere with abstinence and responsible living.

Mental Health

  • Positive Personality & Lifestyle Change: Personality and life style changes that support continued abstinence

Lifestyle

Substance Abuse Treatment Services:  
Treatment Episode Data Set (TEDS), 2003

  • data on treatment completion rates by type of substance abuse care (inpatient, outpatient, hospital, methadone maintenance, etc.)  
  • Among the 888,432 discharges from substance abuse treatment reported
  • 42% were from outpatient treatment,
  • 23% from detoxification,
  • 12% were from intensive outpatient treatment,
  • 8% from long-term residential treatment,
  • 8% from short term residential treatment,
  • 5% from methadone treatment
  • 1% from hospital residential treatment.

Treatment completion rate from 888,432 discharges (2003)

  • Overall, treatment was completed by 41% of the substance abuse treatment discharges. The treatment completion rate was highest from short term treatment programs
  • 69% from hospital residential treatment,
  • 64% from short term residential, and
  • 55% from detoxification).
  • The treatment completion rate was 41% for long term residential treatment and 38% for outpatient treatment.

Pharmacological Therapies

  • Methadone
  • Naloxone and Naltrexone
  • Nicotine Replacement
  • Clonidine
  • Antabuse
  • Acomprosate and Topiramate

Methadone

  • An opioid agonist
  • Long-acting synthetic opiate medication administered orally for a sustained period at a dosage sufficient to prevent opiate withdrawal and decrease craving
  • Patients stabilized on adequate, sustained dosages of methadone can function normally.

Naloxone

  • A short-acting opioid antagonist, naloxone (Narcan), is often used in the emergency treatment of opioid overdoses.

Naltrexone

  • A long-acting synthetic opioid antagonist
  • Individuals must be opioid-free for several days before taking naltrexone in order to avoid withdrawal symptoms.
  • An extended release preparation of the drug (Vivitrol) have been shown to reduce relapse to problem drinking in some patients.

Nicotine Replacement

  • Nicotine gum, transdermal patches, nasal sprays and inhalers

Clonidine

  • Clonidine is not addictive and does not cause euphoria, but it does block cravings for some drugs.

Antabuse

  • Used for treating alcoholics.
  • Causes nausea, vomiting, flushing, and anxiety if an individual consumes alcohol while taking the drug.
  • A deterrent drug.

Acomprosate and Topiramate

  • Novel mechanism of action
  • Act on the glutamate and gamma-aminobutyric acid (GABA) neurotransmitter systems.

Drug Addiction Treatment Act

  • Subutex and Suboxone tablets approved for the treatment of opiate dependence by specially trained physicians. Accordingly, the drugs can be prescribed in an office setting and, therefore, can provide greater access to patients needing treatment.

Buprenorphine

  • A partial agonist at opioid receptors.
  • Reduces or eliminates withdrawal symptoms associated with opioid dependence but generally does not produce the euphoria and sedation caused by other opioids.
  • Available in two formulations—Subutex, which contains only buprenorphine, and Suboxone, which contains both buprenorphine and naloxone.