Principles of Effective Drug Treatment and Rehabilitation

Principles of Effective Treatment from the United States National Drug and Alcohol Treatment Service

Drug addiction is a complex illness characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. While the path to drug addiction begins with the voluntary act of taking drugs, over time a person’s ability to choose not to do so becomes compromised, and seeking and consuming the drug becomes compulsive. This behavior results largely from the effects of prolonged drug exposure on brain functioning. Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior.

Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. 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 typically a chronic disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.

Too often, addiction goes untreated: According to the National Survey on Drug Use and Health (NSDUH), 23.2 million persons (9.4% of the U.S. population) aged 12 or older needed treatment for an illicit drug or alcohol use problem in 2007. Of these individuals, 2.4 million (10.4%) received treatment at a specialty facility (i.e., hospital, drug or alcohol rehabilitation or mental health center). Thus, 20.8 million persons (8.4 % of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive it.

Scientific research since the mid–1970s shows that treatment can help patients addicted to drugs stop using, avoid relapse, and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment programs:

  • Addiction is a complex but treatable disease that affects brain function and behavior.
  • No single treatment is appropriate for everyone.
  • Treatment needs to be readily available.
  • Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
  • Remaining in treatment for an adequate period of time is critical.
  • Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment.
  • 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.
  • Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long–term drug abuse.
  • Treatment does not need to be voluntary to be effective.
  • Drug use during treatment must be monitored continuously, as lapses during treatment do occur.

When looking for drug rehab centers it is valuable to keep these facts in mind. Even the best rehab centers have many failed attempts to beat drug addiction. By finding centers that have adopted scientifically tested strategies success rates can be improved.

Related: How Effective is Treatment for Drug Addiction?Methods to Treat Drug and Alcohol AddictionDrug Rehab Centers in Los AngelesUniversity of Wisconsin-Madison Program Aims to Improve Drug Treatment

Decline in the Misuse of Prescription Drugs in the USA

The US Department of Health & Human Services Substance – Abuse & Mental Health Services Administration reports a significant decline in the misuse of prescription drugs. The misuse of prescription drugs decreased significantly between 2007 and 2008 among those aged 12 and older, including among adolescents, according to 2008 National Survey on Drug Use and Health (NSDUH). However, the national survey showed that the overall level of current illicit drug use has remained level at about 8%.

The annual NSDUH report also indicated that progress has been made in curbing other types of the illicit drug use. For example, past month methamphetamine use among those aged 12 and older dropped sharply from approximately 529,000 people in 2007 to 314,000 in 2008. Similarly, the level of current cocaine use among the population aged 12 and older has decreased from 1.0% in 2006 to 0.7% in 2008.

Promising results from the latest survey also were also found for the most part among youth (12 to 17 year olds). Among youth there was a significant decline in overall past month illicit drug use, from 11.6% in 2002 to 9.3% in 2008. The rate of current marijuana use among youth has remained level at about 6.7% over the past few years while there have been significant decreases in the current use of alcohol, cigarettes and non-medical use of prescription drugs since 2007.

Historically, young adults have had the highest rates of substance abuse, and for most types of illicit substance abuse the levels have remained steady over the past year. However, over the past three years there has been a steady drop in the rate of heavy alcohol use by full time college students aged 18 to 22 – from a high of 19.5% in 2005 to 16.3% in 2008.

“The survey findings are important because they often point to emerging patterns of substance abuse,” said Gil Kerlikowske, Director of National Drug Control Policy. “Although we see some success reversing trends in prescription drug abuse, there are indications that progress in other areas may be at a standstill, or even slipping back, particularly among youth.”

The NSDUH continues to show a vast disparity between the number of number of people needing specialized treatment for a substance abuse problem and the number who actually receive it. According to the survey 23.1 million Americans need specialized treatment for a substance abuse problem, but only 2.3 million (or roughly 10 percent of them) get it.

The complete survey findings are available on the SAMHSA web site.

Related: Prescription Drug Abuse: Pain Killers Can Lead to AdditionMethamphetamine Abuse Costs U.S. $23.4 BillionDrug Rehab Centers in Los Angeles

Research on the Brain and Behavior on Addiction

New research on the brain and behavior clarifies the mysteries of addiction by Craig Lambert, Harvard Magazine, March 2000.

Early experiences with drugs, whether in the womb or as an adult, have ineradicable effects. Drug users often describe a wish to recapture the bliss of their first high. But this goal proves elusive because once the brain has neuroadapted to drugs, it is physiologically and structurally changed. The director of the National Institute on Drug Abuse and many others argue that voluntary drug consumption alters the brain in ways that lead to involuntary drug consumption. The question of whether drug habits are voluntary or not leads us to ask how people get over their addictions, and raises some of the moral issues surrounding compulsive behavior.

Addiction is not all pharmacology, neurotransmitters, and intrapsychic states; the social settings of drug consumption have powerful effects. They can influence basic brain chemistry–which is one reason Gene Heyman rejects the notion that “addictive behavior is insensitive to persuasion, that there’s an irresistible urge to take the drug.” Heyman agrees that drugs alter the brain, but disputes the idea that they change the brain in ways that make choice impossible–he does not believe, in other words, that neuroadaptation makes drug use involuntary. Exhibit A, he says, is 50 million ex-smokers who have voluntarily ended their intake of nicotine.

One reason people believe drug use is involuntary is that recovery rates for addicts treated at clinics are quite bad. Within one year of treatment, relapse rates of 67 to 90 percent are common for alcohol, opiate, cocaine, and tobacco users. “But most of the people who become addicted to drugs don’t go to clinics,” says Heyman. “Actually, only 30 to 40 percent go to clinics. Yet this clinic population has greatly influenced our vision and concept of addiction.”

It turns out that addicts who don’t go to clinics have much higher recovery rates.

This is an interesting article with interesting data. Remember the different recover rates for those that go to clinics and those who does not mean going to a clinic reduces the odds of success. It seems reasonable to guess most of those that go to clinics are drawn from the subset that failed to quit without going to a clinic. So it could be that fail to quit on their own then will fail only quit on their own 3% of the time and quit in a clinic 10% of the time (these numbers are not based on anything just an example of what you must consider about the above statistics).

Even though cigarette smoking is the direct cause of 400,000 American deaths annually, while alcohol directly causes only 100,000 deaths, “alcoholism is a major reason that people don’t stop smoking,” says Vaillant. “Those who keep on smoking after age 50 tend to be alcoholics.” In hospitals, alcoholics cost six times as much as other patients. Half of all people who show up in emergency rooms with severe multiple fractures are alcoholics. “But the emergency rooms treating multiple fractures ignore blood alcohol levels,” Vaillant says. “The causal link isn’t made.”

“No other drug of addiction impairs one’s aversion to punishment the way alcohol does,” he continues. “Yes, compulsive gambling impairs your aversion to being poor, and heroin use impairs your aversion to being arrested. But alcoholism goes across the board. When drinking, people are much more likely to engage in all kinds of dangerous, life-threatening behavior–wife beating, child abuse, unprotected sex with strangers, smoking, drunk driving. You can be five foot two and willing to take on anyone in the bar.”

Related: Alcohol is a Major Cause of Drug Rehab AdmissionsHow Effective is Drug Addiction Treatment?Methods to Treat AddictionWhy Can’t Drug Addicts Quit on Their Own?

Improving Addiction Treatment with The University of Wisconsin – Madison

University of Wisconsin-Madison based program aims to better drug treatment

Green-Milon’s apparent success in overcoming her addictions is all too rare, experts say. Only about a tenth of the 24 million Americans who need drug treatment get it, according to the National Institute on Drug Abuse, and at least half of them relapse.

Part of the challenge, scientists say, is that addiction, like heart disease, high blood pressure and diabetes, is a chronic condition; it changes the chemistry of the brain. But there’s another hurdle that’s getting attention: treatment programs, with their voice-mail systems and multiple forms to fill out, aren’t very patient-friendly, especially to people whose lives present many barriers to staying in treatment.

A national program, based at UW-Madison, is trying to change that by bringing process improvements to drug treatment. The Network for the Improvement of Addiction Treatment, or NIATx, attempts to get addicts into treatment quicker and retain more of them by making the programs more appealing.

24 million Americans need treatment for illicit drug or alcohol problems.
2.5 million get the treatment they need.
The economic cost of substance abuse exceeds $500 billion a year (including alcohol and tobacco; for just illicit drugs, it’s $181 billion).

The NIATx (formerly know as the Network for the Improvement of Addiction Treatment) at the University of Wisconsin – Madison is focused on improving the success of addition treatment.

Use what you learned in Walk-through exercises (See the NIATx Conducting a Walk-through guide for guidance) to identify problems in processes within your organization from the clients’ point of view. Consider changes to test based on that experience. Prior to starting, you should decide the parameters of the change project, including where (e.g., location) you wish to introduce the change, as well which clients (e.g., level of care, population) you expect to impact.

The PDSA Cycle is an efficient way to learn what will work in your organization, and should be the foundation of every change you make. The PDSA Cycle begins with a Plan, and ends with Action based on the learning gained from the Plan, Do, and Study phases of the cycle

They also offer many case studies on improvement successes by treatment centers.

Related: How Effective is Drug Addiction Treatment?Center for Substance Abuse TreatmentMethods to Treat Addiction

Combination Strategy to Treat Alcohol Dependence

New combination of treatments is effective for alcohol dependence

McLean Hospital researchers, along with colleagues from 11 other study sites nationwide, report that the medication naltrexone and up to 20 sessions of alcohol counseling delivered by a behavioral specialist are equally effective treatments for alcohol dependence when delivered with structured medical management in the Journal of the American Medical Association.

Results from the National Institutes of Health-supported Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study show that patients who received naltrexone, specialized alcohol counseling, or both demonstrated the best drinking outcomes after 16 weeks of outpatient treatment. All patients also received Medical Management, an intervention that consisted of nine brief, structured outpatient sessions provided by a health care professional. Contrary to expectations, the researchers found no effect on drinking of the medication acamprosate and no additive benefit from adding acamprosate to naltrexone.

“This was the largest clinical trial looking at the effectiveness of pharmacologic and behavioral treatments for alcohol dependence ever conducted and the results are promising,” said Roger Weiss, clinical director of the Alcohol and Drug Abuse Treatment Program for McLean Hospital, a Harvard Medical School affiliate. Weiss was also the principal investigator of COMBINE for the McLean study site.

Related: Why Can’t Drug Addicts Quit on Their Own?Methods to Treat Addiction

The Rise and Fall of America’s First Prison for Drug Addicts

cover of the Narcotic Farm

The Narcotic Farm: The Rise and Fall of America’s First Prison for Drug Addicts is a book exploring an experiment to deal with addicted criminals.

The farm was the first place to look at drug addicts as patients that were in need of treatment instead of criminals in need of punishment. The farm did experiments to learn about addiction including on methadone (which is commonly used to try and ease the transition from narcotic addition today). Certainly the methods practiced on the farm were of debatable ethical ground however there was a great deal of learning and desire to learn and treat drug addition.

From 1935 until 1975, just about every junkie busted for dope went to the Narcotic Farm. Equal parts federal prison, treatment center, farm, and research laboratory, the Farm was designed to rehabilitate addicts and help researchers discover a cure for drug addiction. Although it began as a bold and ambitious public works project, and became famous as a rehabilitation center frequented by great jazz musicians among others, the Farm was shut down forty years after it opened amid scandal over its drug-testing program, which involved experiments where inmates were being used as human guinea pigs and rewarded with heroin and cocaine for their efforts.

Published to coincide with a documentary to be aired on PBS, The Narcotic Farm includes rare and unpublished photographs, film stills, newspaper and magazine clippings, government documents, as well as interviews, writings, and anecdotes from the prisoners, doctors, and guards that trace the Farm’s noble rise and tumultuous fall, revealing the compelling story of what really happened inside the prison walls.

Listen to an NPR podcast on America’s First Drug-Treatment Prison

Related: How Effective is Drug Addiction Treatment?Drug Rehabilitation Centers in CaliforniaWhy Can’t Drug Addicts Quit on Their Own?

Why Can’t Drug Addicts Quit on Their Own?

From the United States National Institute of Health, Principles of Drug Addiction Treatment: A Research Based Guide – Why can’t drug addicts quit on their own?

Nearly all addicted individuals believe in the beginning that they can stop using drugs on their own, and most try to stop without treatment. However, most of these attempts result in failure to achieve long-term abstinence. Research has shown that long-term drug use results in significant changes in brain function that persist long after the individual stops using drugs. These drug-induced changes in brain function may have many behavioral consequences, including the compulsion to use drugs despite adverse consequences – the defining characteristic of addiction.

Long-term drug use results in significant changes in brain function that persist long after the individual stops using drugs.

Understanding that addiction has such an important biological component may help explain an individual’s difficulty in achieving and maintaining abstinence without treatment. Psychological stress from work or family problems, social cues (such as meeting individuals from one’s drug-using past), or the environment (such as encountering streets, objects, or even smells associated with drug use) can interact with biological factors to hinder attainment of sustained abstinence and make relapse more likely. Research studies indicate that even the most severely addicted individuals can participate actively in treatment and that active participation is essential to good outcomes.

Source: NIH Publication No. 00-4180 July 2000

Related: Methods to Treat Addictionstatistics on binge drinkingDrug Treatment Success Rates in England

How Effective is Drug Addiction Treatment?

National Institute on Drug Abuse, NIH on how effective is drug addiction treatment:

According to several studies, drug treatment reduces drug use by 40 to 60 percent and significantly decreases criminal activity during and after treatment. For example, a study of therapeutic community treatment for drug offenders (See Treatment Section) demonstrated that arrests for violent and nonviolent criminal acts were reduced by 40 percent or more. Methadone treatment has been shown to decrease criminal behavior by as much as 50 percent. Research shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV-related illnesses. Treatment can improve the prospects for employment, with gains of up to 40 percent after treatment.

Although these effectiveness rates hold in general, individual treatment outcomes depend on the extent and nature of the patient’s presenting problems, the appropriateness of the treatment components and related services used to address those problems, and the degree of active engagement of the patient in the treatment process.

Generally, for residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated. For methadone maintenance, 12 months of treatment is the minimum, and some opiate-addicted individuals will continue to benefit from methadone maintenance treatment over a period of years.

Good outcomes are contingent on adequate lengths of treatment.

Related: Center for Substance Abuse Treatment, HHSDrug Treatment Success Rates in EnglandMethods to Treat Addiction

Center for Substance Abuse Treatment

The Center for Substance Abuse Treatment is part of the United States Department for Health and Human Services. CSAT promote the quality and availability of community-based substance abuse treatment services. CSAT also supports free treatment referral service to link people with the community-based substance abuse services they need.

The treatment locator includes more than 11,000 addiction treatment programs, including residential treatment centers, outpatient treatment programs, and hospital inpatient programs for drug addiction and alcoholism. Listings include treatment programs for marijuana, cocaine, and heroin addiction, as well as drug and alcohol treatment programs for adolescents, and adults.

CSAT offers a list of questions to find answers to when looking for a rehab center, including:

  • Is the program run by state-accredited, licensed and/or trained professionals?
  • Is long-term aftercare support and/or guidance encouraged, provided and maintained?
  • Is there ongoing monitoring of possible relapse to help guide patients back to abstinence?
  • I think it also makes sense to learn about the success of those using the center and how the rehab center’s treatment matches your needs.

    Related: Methods to Treat AddictionStudy: Drug Treatment Success Rates in EnglandAging of the Population in Rehab

    Study: Drug Treatment Success Rates in England

    Trends in drop out, drug free discharge and rates of re-presentation: a retrospective cohort study of drug treatment clients in the North West of England, published in 2006.

    The proportion of individuals dropping out has increased from 7.2% in 1998 to 9.6% in 2001/02 (P < 0.001). The proportion DDF [Discharged Drug Free] has fallen from 5.8% to 3.5% (P < 0.001). Drop out was more likely in later years, by those of younger age and by CJ [Criminal Justice] referrals. The proportion re-presenting to treatment in the following year increased from 27.8% in 1998 to 44.5% in 2001/02 (P < 0.001) for those DDF, and from 22.9% to 48.6% (P < 0.001) for those who dropped out. Older age and prior treatment experience predicted re-presentation. Outcome (drop out or DDF) did not predict re-presentation. Conclusion Increasing numbers in treatment is associated with an increased proportion dropping out and an ever-smaller proportion DDF. Rates of drop out are significantly higher for those coerced into treatment via the CJ system. Rates of re-presentation are similar for those dropping out and those DDF. Encouragingly, those who need to re-engage with treatment, particularly those who drop out, are doing so more quickly. The impact of coercion on treatment outcomes and the appropriateness of aftercare provision require further consideration. ... In many countries the health, social and criminal justice consequences of problematic drug use create an economic burden estimated at between 0.5% and 1.3% of gross domestic product. Providing drug treatment programmes for drug users is considered both a cost effective and humanitarian response

    Related: Methods to Treat AddictionAging of the Population in Rehab