Principles Of Drug Addiction Treatment - Drugabuse.gov

458.9.10.An individual’s treatment and servicesplan must be assessed continually andmodified as necessary to ensure thatit meets his or her changing needs. Apatient may require varying combinations of services andtreatment components during the course of treatment andrecovery. In addition to counseling or psychotherapy, apatient 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.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.Medically assisted detoxificationis only the first stage of addictiontreatment and by itself does little tochange long-term drug abuse. AlthoughUMLQKITTa I[[Q[\ML LM\W QÅKI\QWV KIV [INMTa UIVIOM \PM acute physical symptoms of withdrawal and can, forsome, pave the way for effective long-term addiction\ZMI\UMV\ LM\W QÅKI\QWV ITWVM Q[ ZIZMTa []NÅKQMV\ \W PMTX addicted individuals achieve long-term abstinence. Thus,patients should be encouraged to continue drug treatmentNWTTW QVO LM\W QÅKI\QWV 5W\Q I\QWVIT MVPIVKMUMV\ IVL incentive strategies, begun at initial patient intake, canimprove treatment engagement.11.Treatment does not need to bevoluntary to be effective. Sanctions orenticements from family, employment settings, and/or theKZQUQVIT R][\QKM [a[\MU KIV [QOVQÅKIV\Ta QVKZMI[M \ZMI\UMV\ entry, 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 testpatients for the presence of HIV/AIDS,hepatitis B and C, tuberculosis, andother infectious diseases, as wellas provide targeted risk-reductioncounseling, linking patients totreatment if necessary. Typically, drug abusetreatment addresses some of the drug-related behaviorsthat put people at risk of infectious diseases. Targetedcounseling focused on reducing infectious disease riskcan help patients further reduce or avoid substancerelated and other high-risk behaviors. Counseling canalso help those who are already infected to manage theirillness. Moreover, engaging in substance abuse treatmentcan facilitate adherence to other medical treatments.Substance abuse treatment facilities should provide onsite,rapid HIV testing rather than referrals to offsite testing—research shows that doing so increases the likelihoodthat patients will be tested and receive their test results.Treatment providers should also inform patients thathighly active antiretroviral therapy (HAART) has proveneffective in combating HIV, including among drugabusing populations, and help link them to HIV treatmentif they test positive.

6Frequently AskedQuestionsTreatment varies depending on thetype of drug and the characteristicsof the patient. The best programsprovide a combination of therapiesand other services.1.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 impulse\W ][M LZ]O[ LM[XQ\M IL MZ[M KWV[MY]MVKM[ \PM LMÅVQVO characteristic 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 fundamentalJQWTWOQKIT KWUXWVMV\ UIa PMTX M XTIQV \PM LQNÅK]T\a of 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 isIV M[[MV\QIT KWUXWVMV\ NWZ OWWL W]\KWUM[ IVL KIV JMVMÅ\ even the most severely addicted individuals.7

89combination of treatments will vary depending on thepatient’s individual needs and, often, on the types of drugsthey use.Components of Comprehensive Drug Abuse TreatmentChild CareServicesFamilyServicesHousing py andCounselingTreatment PlanSubstance UseMonitoringClinicaland CaseManagementPharmacotherapySelf-Help/PeerSupport GroupsDrug addiction treatment can includemedications, behavioral therapies, ortheir combination.Mental HealthServicesTreatment medications, such as methadone,buprenorphine, and naltrexone (including a new longacting formulation), are available for individuals addictedto opioids, while nicotine preparations (patches, gum,lozenges, and nasal spray) and the medications vareniclineand bupropion are available for individuals addicted to\WJIKKW ,Q[]TÅZIU IKIUXZW[I\M IVL VIT\ZM WVM IZM medications available for treating alcohol dependence,1which commonly co-occurs with other drug addictions,including addiction to prescription icesEducationalServicesHIV/AIDSServicesTreatments for prescription drug abuse tend to besimilar to those for illicit drugs that affect the same brainsystems. For example, buprenorphine, used to treat heroinaddiction, can also be used to treat addiction to opioidpain medications. Addiction to prescription stimulants,which affect the same brain systems as illicit stimulants likecocaine, can be treated with behavioral therapies, as thereare not yet medications for treating addiction to thesetypes of drugs.The 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, take many different forms,and last for different lengths of time. Because drugaddiction is typically a chronic disorder characterized byoccasional relapses, a short-term, one-time treatment is][]ITTa VW\ []NÅKQMV\ .WZ UIVa \ZMI\UMV\ Q[ I TWVO \MZU process that involves multiple interventions and regularmonitoring.Behavioral 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.There are a variety of evidence-based approachesto treating addiction. Drug treatment can includebehavioral therapy (such as cognitive-behavioraltherapy or contingency management), medications, or\PMQZ KWUJQVI\QWV PM [XMKQÅK \aXM WN \ZMI\UMV\ WZ 1Another drug, topiramate, has also shown promise in studies and is sometimes prescribed (off-label)for this purpose although it has not received FDA approval as a treatment for alcohol dependence.

1011Many treatment programs employ both individual andgroup therapies. Group therapy can provide socialreinforcement and help enforce behavioral contingenciesthat promote abstinence and a non-drug-using lifestyle.Some of the more established behavioral treatments, suchas contingency management and cognitive-behavioraltherapy, are also being adapted for group settings toQUXZW M MNÅKQMVKa IVL KW[\ MNNMK\Q MVM[[ 0W M MZ particularly in adolescents, there can also be a dangerof unintended harmful (or iatrogenic) effects of grouptreatment—sometimes group members (especially groupsof highly delinquent youth) can reinforce drug use andthereby derail the purpose of the therapy. Thus, trainedcounselors should be aware of and monitor for such effects.Because they work on different aspects of addiction,combinations of behavioral therapies and medications(when available) generally appear to be more effective thaneither approach used alone.Finally, people who are addicted to drugs often suffer fromother health (e.g., depression, HIV), occupational, legal,familial, and social problems that should be addressedconcurrently. The best programs provide a combination oftherapies and other services to meet an individual patient’sneeds. Psychoactive medications, such as antidepressants,anti-anxiety 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. Inaddition, most people with severe addiction abuse multipledrugs and require treatment for all substances abused.Treatment for drug abuse and addictionis delivered in many different settingsusing a variety of behavioral andpharmacological approaches.3.How effective is drug addictiontreatment?In addition to stopping drug abuse, the goal of treatmentis to return people to productive functioning in the family,workplace, and community. According to research thattracks individuals in treatment over extended periods,most people who get into and remain in treatment stopusing drugs, decrease their criminal activity, and improvetheir occupational, social, and psychological functioning.For example, methadone treatment has been shown toincrease participation in behavioral therapy and decreaseboth drug use and criminal behavior. However, individualtreatment outcomes depend on the extent and nature ofthe patient’s problems, the appropriateness of treatmentand related services used to address those problems, andthe quality of interaction between the patient and his orher treatment providers.Relapse rates for addiction resemblethose of other chronic diseases suchas diabetes, hypertension, and asthma.Like other chronic diseases, addiction can be managedsuccessfully. Treatment enables people to counteractaddiction’s powerful disruptive effects on the brain andbehavior and to regain control of their lives. The chronicnature of the disease means that relapsing to drug abuse isnot only possible but also likely, with symptom recurrencerates similar to those for other well-characterized chronicmedical illnesses—such as diabetes, hypertension, andI[\PUI [MM ÅO]ZM ¹ WUXIZQ[WV WN :MTIX[M :I\M[ Between Drug Addiction and Other Chronic Illnesses”)—that also have both physiological and behavioralcomponents.

1213Percentage of Patients Who RelapseTY PE I DIABETES30 to 50%DR UG ADDICTION40 to 60%H Y PE RTENS IONWhy is addiction treatment evaluated differently?Both require ongoing careHypertension TreatmentSEVE R ITY O F C O N D ITIO NComparison of Relapse RatesBetween Drug Addiction andOther Chronic Illnesses8877665544332211005 0 t o 7 0%Addiction TreatmentPR ED UR INGPO S TPRED URI N GS T AGE O F T RE AT M E N TASTH MA5 0 t o 7 0%Unfortunately, when relapse occurs many deem treatmenta failure. This is not the case: Successful treatment foraddiction typically requires continual evaluation andUWLQÅKI\QWV I[ IXXZWXZQI\M [QUQTIZ \W \PM IXXZWIKP \ISMV for other chronic diseases. For example, when a patient isreceiving active treatment for hypertension and symptomsdecrease, treatment is deemed successful, even thoughsymptoms may recur when treatment is discontinued.For the addicted individual, lapses to drug abuse do notindicate failure—rather, they signify that treatment needsto be reinstated or adjusted, or that alternate treatmentQ[ VMMLML [MM ÅO]ZM ¹?Pa Q[ )LLQK\QWV ZMI\UMV\ Evaluated Differently?”).4.Is drug addiction treatment worthits cost?Substance abuse costs our Nation over 600 billionannually and treatment can help reduce these costs. Drugaddiction treatment has been shown to reduce associatedhealth and social costs by far more than the cost of thetreatment itself. Treatment is also much less expensivethan its alternatives, such as incarcerating addictedpersons. For example, the average cost for 1 full yearof methadone maintenance treatment is approximately 4,700 per patient, whereas 1 full year of imprisonmentcosts approximately 24,000 per person.Drug addiction treatment reducesdrug use and its associated healthand social costs.According to several conservative estimates, every dollarinvested in addiction treatment programs yields a returnof between 4 and 7 in reduced drug-related crime,criminal justice costs, and theft. When savings related tohealthcare are included, total savings can exceed costsby a ratio of 12 to 1. Major savings to the individual and\W [WKQM\a IT[W [\MU NZWU NM MZ QV\MZXMZ[WVIT KWVÆQK\[# greater workplace productivity; and fewer drug-relatedaccidents, including overdoses and deaths.PO S T

14155.How long does drug addictiontreatment usually last?pressure from the criminal justice system, child protectionservices, employers, or family. Within a treatment program,successful clinicians can establish a positive, therapeuticrelationship with their patients. The clinician shouldensure that a treatment plan is developed cooperativelywith the person seeking treatment, that the plan isfollowed, and that treatment expectations are clearlyunderstood. Medical, psychiatric, and social servicesshould also be available.Individuals progress through drug addiction treatmentat various rates, so there is no predetermined length oftreatment. However, research has shown unequivocallythat good outcomes are contingent on adequate treatmentlength. Generally, for residential or outpatient treatment,participation for less than 90 days is of limited effectiveness,IVL \ZMI\UMV\ TI[\QVO [QOVQÅKIV\Ta TWVOMZ Q[ ZMKWUUMVLML NWZ maintaining positive outcomes. For methadone maintenance,12 months is considered the minimum, and some opioidILLQK\ML QVLQ QL]IT[ KWV\QV]M \W JMVMÅ\ NZWU UM\PILWVM maintenance for many years.Whether a patient stays in treatmentdepends on factors associated withboth the individual and the program.Because some problems (such as serious medical ormental illness or criminal involvement) increase thelikelihood of patients dropping out of treatment, intensiveinterventions may be required to retain them. After acourse of intensive treatment, the provider should ensurea transition to less intensive continuing care to supportand monitor individuals in their ongoing recovery.Good outcomes are contingent onadequate treatment length.Treatment dropout is one of the major problemsencountered by treatment programs; therefore, motivationaltechniques that can keep patients engaged will also improveoutcomes. By viewing addiction as a chronic disease andoffering continuing care and monitoring, programs cansucceed, but this will often require multiple episodes oftreatment and readily readmitting patients that have relapsed.6.What helps people stay in treatment?Because successful outcomes often depend on a person’s[\IaQVO QV \ZMI\UMV\ TWVO MVW]OP \W ZMIX Q\[ N]TT JMVMÅ\[ strategies for keeping people in treatment are critical.Whether a patient stays in treatment depends on factorsassociated with both the individual and the program.Individual factors related to engagement and retentiontypically include motivation to change drug-using behavior;degree of support from family and friends; and, frequently,7.How do we get more substanceabusing people into treatment?1\ PI[ JMMV SVW V NWZ UIVa aMIZ[ \PI\ \PM ¹\ZMI\UMV\ gap” is massive—that is, among those who need treatmentfor a substance use disorder, few receive it. In 2011, 21.6million persons aged 12 or older needed treatment for anillicit drug or alcohol use problem, but only 2.3 millionreceived treatment at a specialty substance abuse facility.Reducing this gap requires a multipronged approach.Strategies include increasing access to effective treatment,achieving insurance parity (now in its earliest phase ofimplementation), reducing stigma, and raising awareness

1617among both patients and healthcare professionals ofthe value of addiction treatment. To assist physicians inidentifying treatment need in their patients and makingappropriate referrals, NIDA is encouraging widespreaduse of screening, brief intervention, and referral totreatment (SBIRT) tools for use in primary care settingsthrough its NIDAMED initiative. SBIRT, which evidenceshows to be effective against tobacco and alcohol use—and, increasingly, against abuse of illicit and prescriptiondrugs—has the potential not only to catch people beforeserious drug problems develop but also to identify peoplein need of treatment and connect them with appropriatetreatment providers.8.How can family and friends make adifference in the life of someoneneeding treatment?Family and friends can play critical roles in motivatingindividuals with drug problems to enter and stay intreatment. Family therapy can also be important,especially for adolescents. Involvement of a familyUMUJMZ WZ [QOVQÅKIV\ W\PMZ QV IV QVLQ QL]IT¼[ \ZMI\UMV\ XZWOZIU KIV [\ZMVO\PMV IVL M \MVL \ZMI\UMV\ JMVMÅ\[ 9.Where can family members go forinformation on treatment options?Trying to locate appropriate treatment for a loved one,M[XMKQITTa ÅVLQVO I XZWOZIU \IQTWZML \W IV QVLQ QL]IT¼[ XIZ\QK]TIZ VMML[ KIV JM I LQNÅK]T\ XZWKM[[ 0W M MZ \PMZM are some resources to help with this process. For example,NIDA’s handbook Seeking Drug Abuse Treatment: KnowWhat to Ask WNNMZ[ O]QLIVKM QV ÅVLQVO \PM ZQOP\ \ZMI\UMV\ program. Numerous online resources can help locate alocal program or provide other information, including: The Substance Abuse and Mental Health ServicesAdministration (SAMHSA) maintains a Web site(findtreatment.samhsa.gov) that shows the location ofresidential, outpatient, and hospital inpatient treatmentprograms for drug addiction and alcoholism throughoutthe country. This information is also accessible bycalling 1-800-662-HELP. The National Suicide Prevention Lifeline (1-800-273TALK) offers more than just suicide prevention—itcan also help with a host of issues, including drugand alcohol abuse, and can connect individuals with anearby professional. The National Alliance on Mental Illness (nami.org) andMental Health America (mentalhealthamerica.net) areITTQIVKM[ WN VWVXZWÅ\ [MTN PMTX []XXWZ\ WZOIVQbI\QWV[ for patients and families dealing with a variety ofUMV\IT LQ[WZLMZ[ *W\P PI M ;

seeking and use that persist even in the face of devastating consequences. This update of the National Institute on Drug Abuse's Principles of Drug Addiction Treatment is intended to address addiction to a wide variety of drugs, including nicotine, alcohol, and illicit and prescription drugs. It is designed to serve as a resource for healthcare