Principles Of Drug Addiction Treatment

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Iprinciples ofdrug addictiontreatmentA research-based guidesecond editionNational Institute on Drug AbuseNational Institutes of HealthU.S. Department of Health and Human Services

II

principles ofdrug addictiontreatmentA research-based guidesecond editionNational Institute on Drug AbuseNational Institutes of HealthU.S. Department of Health and Human Services

AcknowledgmentsiiiiThe National Institute on Drug Abuse wishes to thank the followingindividuals for reviewing this publication.Martin W. Adler, Ph.D.Temple University School of MedicineReese T. Jones, M.D.University of California at San FranciscoAndrea G. Barthwell, M.D.Encounter Medical GroupLinda R. Wolf-Jones, D.S.W.Therapeutic Communities of AmericaKathleen Brady, M.D., Ph.D.Medical University of South CarolinaLinda Kaplan, CAENational Association of Alcoholismand Drug Abuse CounselorsGreg Brigham, Ph.D.MaryhavenLawrence S. Brown, Jr., M.D., M.P.H.Addiction Research andTreatment CorporationJames F. Callahan, D.P.A.American Society ofAddiction MedicineA. Thomas McLellan, Ph.D.University of PennsylvaniaSchool of MedicineG. Alan Marlatt, Ph.D.University of WashingtonNancy K. Mello, Ph.D.Harvard Medical SchoolKathleen M. Carroll, Ph.D.Yale University School of MedicineWilliam R. Miller, Ph.D.University of New MexicoH. Westley Clark, M.D., J.D.,M.P.H., CAS, FASAMCenter for Substance Abuse TreatmentCharles P. O’Brien, M.D., Ph.D.University of PennsylvaniaRichard R. Clayton, Ph.D.University of KentuckyLinda B. Cottler, Ph.D.Washington UniversitySchool of MedicineDavid P. Friedman, Ph.D.Bowman Gray School of MedicineJeffrey Seltzer, M.D.Zucker Hillside HospitalEric J. Simon, Ph.D.New York University Medical CenterJose Szapocznik, Ph.D.University of MiamiMiller School of MedicineGeorge Woody, M.D.University of PennsylvaniaAll materials in this volume are in the public domain and may be usedor reproduced without permission from the Institute or the authors.Citation of the source is appreciated.The U.S. Government does not endorse or favor any specific commercialproduct or company. Trade, proprietary, or company names appearing inthis publication are used only because they are considered essential in thecontext of the studies described.NIH Publication No. 09–4180Printed October 1999; Reprinted July 2000, February 2008; Revised April 2009

ContentsiiAcknowledgmentsvPreface2Principles of Effective Treatment7Frequently Asked Questions7Why do drug-addicted persons keep using drugs?8What is drug addiction treatment?11How effective is drug addiction treatment?12Is drug addiction treatment worth its cost?14How long does drug addictiontreatment usually last?14What helps people stay in treatment?15How do we get more substanceabusing people into treatment?16How can families and friends make a differencein the life of someone needing treatment?16Where can family members go forinformation on treatment options?18How can the workplace play a rolein substance abuse treatment?18What role can the criminal justice systemplay in addressing drug addiction?20What are the unique needs of womenwith substance use disorders?20What are the unique needs of adolescentswith substance use disorders?21Are there specific drug addictiontreatments for older adults?iii

iv22Are there treatments for peopleaddicted to prescription drugs?23Is there a difference between physicaldependence and addiction?23Can a person become addicted to psychotherapeuticsthat are prescribed by a doctor?24How do other mental disorders coexisting withdrug addiction affect drug addiction treatment?24Is the use of medications like methadoneand buprenorphine simply replacingone drug addiction with another?25Where do 12‑step or self-help programsfit into drug addiction treatment?26Can exercise play a role in the treatment process?26How does drug addiction treatment helpreduce the spread of HIV/AIDS, hepatitisC (HCV), and other infectious diseases?29Drug Addiction Treatmentin the United States30General Categories of Treatment Programs35Treating Criminal Justice-Involved DrugAbusers and Addicted Individuals37Evidence-Based Approaches toDrug Addiction Treatment37Pharmacotherapies46Behavioral Therapies63Resources

PrefaceDrug addiction is a complex illness.It is characterized by intense and, at times,uncontrollable drug craving, along with compulsivedrug seeking and use that persist even in the face ofdevastating consequences.Many people do not realize that addiction is a braindisease. While the path to drug addiction begins withthe act of taking drugs, over time a person’s ability tochoose not to do so becomes compromised, and seekingand consuming the drug becomes compulsive. Thisbehavior results largely from the effects of prolonged drugexposure on brain functioning. Addiction affects multiplebrain circuits, including those involved in reward andmotivation, learning and memory, and inhibitory controlover behavior. Some individuals are more vulnerablethan others to becoming addicted, depending on geneticmakeup, age of exposure to drugs, other environmentalinfluences, and the interplay of all these factors.Addiction is often more than just compulsive drugtaking—it can also produce far-reaching consequences.For example, drug abuse and addiction increase aperson’s risk for a variety of other mental and physicalillnesses related to a drug-abusing lifestyle or the toxiceffects of the drugs themselves. Additionally, a widerange of dysfunctional behaviors can result from drugabuse and interfere with normal functioning in thefamily, the workplace, and the broader community.Because drug abuse and addiction have so manydimensions and disrupt so many aspects of an individual’slife, treatment is not simple. Effective treatment programstypically incorporate many components, each directedto a particular aspect of the illness and its consequences.Addiction treatment must help the individual stopusing drugs, maintain a drug-free lifestyle, and achieveproductive functioning in the family, at work, and insociety. Because addiction is a disease, people cannotv

visimply stop using drugs for a few days and be cured. Mostpatients require long-term or repeated episodes of careto achieve the ultimate goal of sustained abstinence andrecovery of their lives.Indeed, scientific research and clinical practicedemonstrate the value of continuing care in treatingaddiction, with a variety of approaches having been testedand integrated in residential and community settings. Aswe look toward the future, we will harness new researchresults on the influence of genetics and environment ongene function and expression (i.e., epigenetics), whichare heralding the development of personalized treatmentinterventions. These findings will be integrated withcurrent evidence supporting the most effective drug abuseand addiction treatments and their implementation, whichare reflected in this guide.This update of the National Institute on Drug Abuse’sPrinciples of Drug Addiction Treatment is intended to addressaddiction to a wide variety of drugs, including nicotine,alcohol, and illicit and prescription drugs. It is designedto serve as a resource for health care providers, familymembers, and other stakeholders trying to address themyriad problems faced by patients in need of treatmentfor drug abuse or addiction.Nora D. Volkow, M.D.DirectorNational Institute on Drug Abuse

Three decades of scientific researchand clinical practice have yieldeda variety of effective approaches todrug addiction treatment.1

Principlesof EffectiveTreatment21.Addiction is a complex but treatabledisease that affects brain function andbehavior. Drugs of abuse alter the brain’s structureand function, resulting in changes that persist long afterdrug use has ceased. This may explain why drug abusersare at risk for relapse even after long periods of abstinenceand despite the potentially devastating consequences.2.No single treatment is appropriatefor everyone. Matching treatment settings,interventions, and services to an individual’s particularproblems and needs is critical to his or her ultimatesuccess in returning to productive functioning in thefamily, workplace, and society.3.Treatment needs to be readily available.Because drug-addicted individuals may be uncertainabout entering treatment, taking advantage of availableservices the moment people are ready for treatmentis critical. Potential patients can be lost if treatment isnot immediately available or readily accessible. As withother chronic diseases, the earlier treatment is offeredin the disease process, the greater the likelihood ofpositive outcomes.4.Effective treatment attends to multipleneeds of the individual, not just hisor her drug abuse. To be effective, treatmentmust address the individual’s drug abuse and anyassociated medical, psychological, social, vocational,and legal problems. It is also important that treatmentbe appropriate to the individual’s age, gender, ethnicity,and culture.5.Remaining in treatment for an adequateperiod of time is critical. The appropriateduration for an individual depends on the type and degreeof his or her problems and needs. Research indicatesthat most addicted individuals need at least 3 months intreatment to significantly reduce or stop their drug use

3and that the best outcomes occur with longer durationsof treatment. Recovery from drug addiction is a longterm process and frequently requires multiple episodes oftreatment. As with other chronic illnesses, relapses to drugabuse can occur and should signal a need for treatment tobe reinstated or adjusted. Because individuals often leavetreatment prematurely, programs should include strategiesto engage and keep patients in treatment.6.Counseling—individual and/or group—and other behavioral therapies are themost commonly used forms of drugabuse treatment. Behavioral therapies vary in theirfocus and may involve addressing a patient’s motivationto change, providing incentives for abstinence, buildingskills to resist drug use, replacing drug-using activitieswith constructive and rewarding activities, improvingproblemsolving skills, and facilitating better interpersonalrelationships. Also, participation in group therapy andother peer support programs during and followingtreatment can help maintain abstinence.7.Medications are an important element oftreatment for many patients, especiallywhen combined with counseling andother behavioral therapies. For example,methadone and buprenorphine are effective in helpingindividuals addicted to heroin or other opioids stabilizetheir lives and reduce their illicit drug use. Naltrexoneis also an effective medication for some opioid-addictedindividuals and some patients with alcohol dependence.Other medications for alcohol dependence includeacamprosate, disulfiram, and topiramate. For personsaddicted to nicotine, a nicotine replacement product(such as patches, gum, or lozenges) or an oral medication(such as bupropion or varenicline) can be an effectivecomponent of treatment when part of a comprehensivebehavioral treatment program.

48.An individual’s treatment and servicesplan must be assessed continually andmodified as necessary to ensure thatit meets his or her changing needs.A patient may require varying combinations of servicesand treatment components during the course of treatmentand recovery. In addition to counseling or psychotherapy,a patient may require medication, medical services, familytherapy, parenting instruction, vocational rehabilitation,and/or social and legal services. For many patients, acontinuing care approach provides the best results, withthe treatment intensity varying according to a person’schanging needs.9.Many drug-addicted individuals alsohave other mental disorders. Becausedrug abuse and addiction—both of which are mentaldisorders—often co-occur with other mental illnesses,patients presenting with one condition should be assessedfor the other(s). And when these problems co-occur,treatment should address both (or all), including the use ofmedications as appropriate.10.Medically assisted detoxification is onlythe first stage of addiction treatmentand by itself does little to changelong-term drug abuse. Although medicallyassisted detoxification can safely manage the acutephysical symptoms of withdrawal and, for some, canpave the way for effective long-term addiction treatment,detoxification alone is rarely sufficient to help addictedindividuals achieve long-term abstinence. Thus, patientsshould be encouraged to continue drug treatmentfollowing detoxification. Motivational enhancement andincentive strategies, begun at initial patient intake, canimprove treatment engagement.

511.Treatment does not need to bevoluntary to be effective. Sanctions orenticements from family, employment settings, and/or thecriminal justice system can significantly increase treatmententry, retention rates, and the ultimate success of drugtreatment interventions.12.Drug use during treatment must bemonitored continuously, as lapsesduring treatment do occur. Knowing theirdrug use is being monitored can be a powerful incentivefor patients and can help them withstand urges to usedrugs. Monitoring also provides an early indication of areturn to drug use, signaling a possible need to adjust anindividual’s treatment plan to better meet his or her needs.13.Treatment programs should assesspatients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis,and other infectious diseases as wellas provide targeted risk-reductioncounseling to help patients modifyor change behaviors that place themat risk of contracting or spreadinginfectious diseases. Typically, drug abusetreatment addresses some of the drug-related behaviorsthat put people at risk of infectious diseases. Targetedcounseling specifically focused on reducing infectiousdisease risk can help patients further reduce or avoidsubstance-related and other high-risk behaviors.Counseling can also help those who are already infectedto manage their illness. Moreover, engaging in substanceabuse treatment can facilitate adherence to other medicaltreatments. Patients may be reluctant to accept screeningfor HIV (and other infectious diseases); therefore, it isincumbent upon treatment providers to encourage andsupport HIV screening and inform patients that highlyactive antiretroviral therapy (HAART) has proveneffective in combating HIV, including among drugabusing populations.

6Treatment varies depending on thetype of drug and the characteristicsof the patient. The best programsprovide a combination of therapiesand other services.

Frequently AskedQuestions1.Why do drug-addicted persons keepusing drugs?Nearly all addicted individuals believe at the outset thatthey can stop using drugs on their own, and most tryto stop without treatment. Although some people aresuccessful, many attempts result in failure to achieve longterm abstinence. Research has shown that long-term drugabuse results in changes in the brain that persist long aftera person stops using drugs. These drug-induced changesin brain function can have many behavioral consequences,including an inability to exert control over the impulseto use drugs despite adverse consequences—the definingcharacteristic of addiction.Long-term drug use results in significantchanges in brain function that canpersist long after the individual stopsusing drugs.Understanding that addiction has such a fundamentalbiological component may help explain the difficultyof achieving and maintaining abstinence withouttreatment. Psychological stress from work, family problems,psychiatric illness, pain associated with medical problems,social cues (such as meeting individuals from one’s drugusing past), or environmental cues (such as encounteringstreets, objects, or even smells associated with drug abuse)can trigger intense cravings without the individual evenbeing consciously aware of the triggering event. Anyone of these factors can hinder attainment of sustainedabstinence and make relapse more likely. Nevertheless,research indicates that active participation in treatment isan essential component for good outcomes and can benefiteven the most severely addicted individuals.7

8Components of Comprehensive Drug Abuse TreatmentChild CareServicesFamilyServicesHousing py andCounselingTreatment PlanSubstance UseMonitoringClinicaland CaseManagementPharmacotherapySelf-Help/PeerSupport GroupsMental rvicesEducationalServicesHIV/AIDSServicesThe best treatment programs provide a combination of therapiesand other services to meet the needs of the individual patient.2.What is drug addiction treatment?Drug treatment is intended to help addicted individualsstop compulsive drug seeking and use. Treatment canoccur in a variety of settings, in many different forms, andfor different lengths of time. Because drug addiction istypically a chronic disorder characterized by occasionalrelapses, a short-term, one-time treatment is usually notsufficient. For many, treatment is a long-term process thatinvolves multiple interventions and regular monitoring.There are a variety of evidence-based approaches totreating addiction. Drug treatment can include behavioraltherapy (such as individual or group counseling, cognitivetherapy, or contingency management), medications, ortheir combination. The specific type of treatment orcombination of treatments will vary depending on the

9patient’s individual needs and, often, on the types of drugsthey use. The severity of addiction and previous efforts tostop using drugs can also influence a treatment approach.Finally, people who are addicted to drugs often suffer fromother health (including other mental health), occupational,legal, familial, and social problems that should beaddressed concurrently.The best programs provide a combination of therapiesand other services to meet an individual patient’s needs.Specific needs may relate to age, race, culture, sexualorientation, gender, pregnancy, other drug use, comorbidconditions (e.g., depression, HIV), parenting, housing, andemployment, as well as physical and sexual abuse history.Drug addiction treatment can includemedications, behavioral therapies, ortheir combination.Treatment medications, such as methadone,buprenorphine, and naltrexone, are available forindividuals addicted to opioids, while nicotine preparations(patches, gum, lozenges, and nasal spray) and themedications varenicline and bupropion are available forindividuals addicted to tobacco. Disulfiram, acamprosate,naltrexone, and topiramate are medications used fortreating alcohol dependence, which commonly co-occurswith other drug addictions. In fact, most people withsevere addiction are polydrug users and require treatmentfor all substances abused. Even combined alcohol andtobacco use has proven amenable to concurrent treatmentfor both substances.Psychoactive medications, such as antidepressants,antianxiety agents, mood stabilizers, and antipsychoticmedications, may be critical for treatment success whenpatients have co-occurring mental disorders, such asdepression, anxiety disorders (including post-traumaticstress disorder), bipolar disorder, or schizophrenia.

10Behavioral therapies can help motivate people toparticipate in drug treatment; offer strategies for copingwith drug cravings; teach ways to avoid drugs and preventrelapse; and help individuals deal with relapse if itoccurs. Behavioral therapies can also help people improvecommunication, relationship, and parenting skills, as wellas family dynamics.Many treatment programs employ both individualand group therapies. Group therapy can providesocial reinforcement and help enforce behavioralcontingencies that promote abstinence and a non-drugusing lifestyle. Some of the more established behavioraltreatments, such as contingency management andcognitive-behavioral therapy, are also be

Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is a disease, people cannot Preface. vi simply stop using drugs for a few days and be cured. Most

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