- Describe the process and effectiveness of pharmacological approaches to substance-use treatment
- Explain cognitive and behavioral approaches to treating substance-related disorders
Drug addiction can be treated, but it’s not simple. Most patients need long-term or repeated care to stop using completely and recover their lives. Addiction treatment must help the person do the following:
- stop using drugs
- stay drug-free
- be productive in the family, at work, and in society
Depending on the severity of substance use disorder, and the given substance, early treatment of acute withdrawal may include medical detoxification. Of note, acute withdrawal from heavy alcohol use should be done under medical supervision to prevent a potentially deadly withdrawal syndrome known as delirium tremens.
Therapists often classify people with chemical dependencies as either interested or not interested in changing. About 11% of Americans with substance use disorder seek treatment, and 40–60% of those people relapse within a year. Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that affect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.
Principles of Effective Treatment
Based on scientific research since the mid-1970s, the following key principles should form the basis of any effective treatment program:
- Addiction is a complex but treatable disease that affects brain function and behavior.
- No single treatment is right for everyone.
- People need to have quick access to treatment.
- Effective treatment addresses all of the patient’s needs, not just their drug use.
- Staying in treatment long enough is critical.
- Counseling and other behavioral therapies are the most commonly used forms of treatment.
- Medications are often an important part of treatment, especially when combined with behavioral therapies.
- Treatment plans must be reviewed often and modified to fit the patient’s changing needs.
- Treatment should address other possible mental disorders.
- Medically assisted detoxification is only the first stage of treatment.
- Treatment doesn’t need to be voluntary to be effective.
- Drug use during treatment must be monitored continuously.
- Treatment programs should test patients for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as teach them about steps they can take to reduce their risk of these illnesses.
What Are Treatments for Drug Addiction?
There are many options that have been successful in treating drug addiction, including:
- behavioral counseling
- medical devices and applications used to treat withdrawal symptoms or deliver skills training
- evaluation and treatment for co-occurring mental health issues such as depression and anxiety
- long-term follow-up to prevent relapse
A range of care with a tailored treatment program and follow-up options can be crucial to success. Treatment should include both medical and mental health services as needed. Follow-up care may include community- or family-based recovery support systems. Various types of programs offer help in drug rehabilitation, including residential treatment (in-patient/out-patient), local support groups, extended care centers, recovery or sober houses, addiction counseling, mental health, and medical care. Some rehab centers offer age- and gender-specific programs.
Drug or Addiction Counseling
Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin, or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and cease substance abuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.
Psychological dependency is addressed in many drug rehabilitation programs by attempting to teach the person new methods of interacting in a drug-free environment. In particular, patients are generally encouraged, or possibly even required, to not associate with peers who still use the addictive substance. Twelve-step programs encourage addicts not only to stop using alcohol or other drugs, but to examine and change habits related to their addictions. For legal drugs such as alcohol, complete abstention—rather than attempts at moderation, which may lead to relapse—is also emphasized (“One is too many, and a thousand is never enough.”) Whether moderation is achievable by those with a history of abuse remains a controversial point.
Medications and devices can be used to manage withdrawal symptoms, prevent relapse, and treat co-occurring conditions.
Withdrawal. Medications and devices can help suppress withdrawal symptoms during detoxification. Detoxification is not in itself “treatment,” but only the first step in the process. Patients who do not receive any further treatment after detoxification usually resume their drug use. One study of treatment facilities found that medications were used in almost 80% of detoxifications (SAMHSA, 2014). In November 2017, the Food and Drug Administration (FDA) granted a new indication to an electronic stimulation device, NSS-2 Bridge, for use in helping reduce opioid withdrawal symptoms. This device is placed behind the ear and sends electrical pulses to stimulate certain brain nerves. Also, in May 2018, the FDA approved lofexidine, a non-opioid medicine designed to reduce opioid withdrawal symptoms.
Relapse prevention. Patients can use medications to help re-establish normal brain function and decrease cravings. Medications are available for the treatment of opioid (heroin, prescription pain relievers), tobacco (nicotine), and alcohol addiction. Scientists are developing other medications to treat stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. People who use more than one drug, which is very common, need treatment for all the substances they use.
- Opioids: Methadone (Dolophine® and Methadose®), buprenorphine (Suboxone®, Subutex®, Probuphine® , and Sublocade™), and naltrexone (Vivitrol®) are used to treat opioid addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone blocks the effects of opioids at their receptor sites in the brain and should be used only in patients who have already been detoxified. All medications help patients reduce drug seeking and related criminal behavior and help them become more open to behavioral treatments. A NIDA study found that once treatment is initiated, both a buprenorphine/naloxone combination and an extended release naltrexone formulation are similarly effective in treating opioid addiction. Because full detoxification is necessary for treatment with naloxone, initiating treatment among active users was difficult, but once detoxification was complete, both medications had similar effectiveness.
- Tobacco: Nicotine replacement therapies have several forms, including the patch, spray, gum, and lozenges. These products are available over the counter. The FDA has approved two prescription medications for nicotine addiction: bupropion (Zyban®) and varenicline (Chantix®). They work differently in the brain, but both help prevent relapse in people trying to quit. The medications are more effective when combined with behavioral treatments, such as group and individual therapy as well as telephone quit lines. A few antidepressants have been proven to be helpful in the context of smoking cessation/nicotine addiction. These medications include bupropion and nortriptyline. Bupropion inhibits the re-uptake of nor-epinephrine and dopamine and has been FDA approved for smoking cessation, while nortriptyline is a tricyclic antidepressant that has been used to aid in smoking cessation but has not been FDA approved for this indication.
- Alcohol: Three medications have been FDA approved for treating alcohol addiction and a fourth, topiramate, has shown promise in clinical trials (large-scale studies with people). The three approved medications are as follows:
- Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some patients. Genetic differences may affect how well the drug works in certain patients.
- Acamprosate (Campral®) may reduce symptoms of long-lasting withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (generally feeling unwell or unhappy). It may be more effective in patients with severe addiction.
- Disulfiram (Antabuse®) interferes with the breakdown of alcohol. Acetaldehyde builds up in the body, leading to unpleasant reactions that include flushing (warmth and redness in the face), nausea, and irregular heartbeat if the patient drinks alcohol. Compliance (taking the drug as prescribed) can be a problem, but it may help patients who are highly motivated to quit drinking.
Below are common treatments for various types of disorders:
benzodiazepines intoxication: flumazenil
benzodiazepines withdrawal: benzodiazepines having a long half-life and gradually cutting down the dosage.
amphetamine intoxication: benzodiazepines for agitation and seizures.
cocaine intoxication: alpha-blockers and benzodiazepines
phencyclidine intoxication: benzodiazepines and rapid-acting antipsychotics
marijuana: N-acetyl cysteine, gabapentin, and dronabinol
- co-occuring conditions: Other medications are available to treat possible mental health conditions, such as depression or anxiety, that may be contributing to the person’s addiction.
Is Addiction a disease?
Scientific journals and popular media outlets often present evidence of alcoholism’s heritability, the neurobiological changes caused by drug use, and the loss of control over substance use as indicators that addiction is a chronic, relapsing brain disease characterized by compulsive drug use (e.g., Miller and Chappel, 1991; Leshner, 1999; Lubman et al., 2004; Quenqua, 2011). However, research also shows that addiction has the highest remission rate of any psychiatric disorder and that most addicts quit drugs without professional assistance, often motivated by financial and familial concerns (e.g., Biernacki, 1986; Robins, 1993; Stinson et al., 2005; Klingemann et al., 2010).
Despite its detrimental effects, addiction continues, thus mirroring a disease-like pattern. To gain a deeper understanding of addiction, we must explore why individuals persist with harmful, seemingly irrational behavior over the long term. In essence, drug addiction is neither purely compulsive nor completely rational.
The disease theory is commonly interpreted to mean that problem drinkers can’t return to normal, problem-free drinking, and therefore treatment should aim for total abstinence. However, this theory is challenged by cases of individuals who, despite previous dependence, have managed to control their drinking.
A pivotal challenge to the disease theory arose from a 1962 study by Dr. D. L. Davies. His follow-up with 93 problem drinkers found that seven were able to drink in a controlled manner. Davies proposed that the prevailing belief — that an alcoholic can never return to normal drinking — should be revisited, while still advising all patients to aim for abstinence. His study prompted other researchers to report similar instances of problem drinkers managing to drink in a controlled manner.
In 1976, a notable study known as the RAND report found that some problem drinkers could learn to consume alcohol moderately. This finding sparked controversy about how people diagnosed with a disease, which supposedly leads to uncontrollable drinking, could achieve moderate consumption. Similar findings have been reported in subsequent studies. A recent long-term (60-year) study by George Vaillant at Harvard Medical School found that “return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence.” Vaillant also observed that “return-to-controlled drinking, as reported in short-term studies, is often a mirage.”
How are behavioral therapies used to treat drug addiction?
Behavioral therapies help patients to
- modify their attitudes and behaviors related to drug use.
- increase healthy life skills.
- persist with other forms of treatment, such as medication.
Patients can receive treatment in many different settings with various approaches.
Outpatient behavioral treatment includes a wide variety of programs for patients who visit a behavioral health counselor on a regular schedule. Most of the programs involve individual or group drug counseling, or both. These programs typically offer forms of behavioral therapy such as
- CBT, which helps patients recognize, avoid, and cope with the situations in which they are most likely to use drugs.
- multidimensional family therapy—developed for adolescents with drug abuse problems as well as their families—which addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.
- motivational interviewing, which makes the most of people’s readiness to change their behavior and enter treatment.
- motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.
Treatment is sometimes intensive at first, where patients attend multiple outpatient sessions each week. After completing intensive treatment, patients transition to regular outpatient treatment, which meets less often and for fewer hours per week to help sustain their recovery. In September 2017, the FDA permitted marketing of the first mobile application, reSET®, to help treat substance use disorders. This application is intended to be used with outpatient treatment to treat alcohol, cocaine, marijuana, and stimulant substance use disorders. In December 2018, the FDA cleared a mobile medical application, reSET®, to help treat opioid use disorders. This application is a prescription cognitive behavioral therapy and should be used in conjunction with treatment that includes buprenorphine and contingency management.
CBT is used to help patients learn how their thought processes play a role in developing their behavior. Cognitive awareness helps them to develop new ways of behaving, thus leading to a change in thinking patterns and emotions.
CBT looks at the habit of smoking cigarettes as a learned behavior, which later evolves into a coping strategy to handle daily stressors. Because smoking is often easily accessible, and quickly allows the user to feel good, it can take precedence over other coping strategies, and eventually work its way into everyday life during non-stressful events as well. CBT aims to target the function of the behavior, as it can vary between individuals, and works to inject other coping mechanisms in place of smoking. It also aims to support individuals suffering from strong cravings, which are a major reported reason for relapse during treatment.
A 2008 controlled study out of Stanford University School of Medicine suggested that CBT may be an effective tool to help maintain abstinence. The results of 304 random adult participants were tracked over the course of one year. During this program, some participants were provided medication, CBT, 24-hour phone support, or some combination of the three methods. At 20 weeks, the participants who received CBT had a 45% abstinence rate versus non-CBT participants, who had a 29% abstinence rate. Overall, the study concluded that emphasizing cognitive and behavioral strategies to support smoking cessation can help individuals build tools for long-term smoking abstinence.
Studies have shown CBT to be an effective treatment for substance abuse. For individuals with substance abuse disorders, CBT aims to reframe maladaptive thoughts, such as denial, minimizing and catastrophizing thought patterns, with healthier narratives. Specific techniques include identifying potential triggers and developing coping mechanisms to manage high-risk situations. Research has shown CBT to be particularly effective when combined with other therapy-based treatments or medication.
Various forms of aversion therapy have been used in the treatment of addiction to alcohol and other drugs since 1932. An approach to the treatment of alcohol dependence that has been wrongly characterized as aversion therapy involves the use of disulfiram a drug that is sometimes used as a second-line treatment under appropriate medical supervision. When a person drinks even a small amount of alcohol, disulfiram causes sensitivity involving highly unpleasant reactions, which can be clinically severe. Rather than as an actual aversion therapy, the nastiness of the disulfiram-alcohol reaction is deployed as a drinking deterrent for people receiving other forms of therapy who actively wish to be kept in a state of enforced sobriety (disulfiram is not administered to active drinkers).
Emetic therapy (chemical) and faradic (electric) aversion therapy have been used to induce aversion for cocaine dependency. It is unknown whether aversion therapy, in the form of rapid smoking (to provide an unpleasant stimulus), can help tobacco smokers overcome the urge to smoke.
Covert conditioning is an approach to mental health treatment that uses the principles of applied behavioral analysis, or cognitive-behavior therapy (CBTs) to assist people in making improvements in their behavior or inner experience. The method relies on the person’s capacity to use imagery for purposes such as mental rehearsal. Effective covert conditioning is said to rely upon careful application of behavioral treatment principles such as a thorough behavioral analysis. Some clinicians include the mind’s ability to spontaneously generate imagery that can provide intuitive solutions or even reprocessing that improves people’s typical reactions to situations or inner material. However, this goes beyond the behavioristic principles on which covert conditioning is based.
Inpatient or residential treatment can also be very effective, especially for those with more severe problems (including co-occurring disorders). Licensed residential treatment facilities offer 24-hour structured and intensive care, including safe housing and medical attention. Residential treatment facilities may use a variety of therapeutic approaches, and they are generally aimed at helping the patient live a drug-free, crime-free lifestyle after treatment. Examples of residential treatment settings include
- therapeutic communities, which are highly structured programs in which patients remain at a residence, typically for six to 12 months. The entire community, including treatment staff and those in recovery, act as key agents of change, influencing the patient’s attitudes, understanding, and behaviors associated with drug use.
- shorter-term residential treatment, which typically focuses on detoxification as well as providing initial intensive counseling and preparation for treatment in a community-based setting.
- recovery housing, which provides supervised, short-term housing for patients, often following other types of inpatient or residential treatment. Recovery housing can help people make the transition to an independent life—for example, helping them learn how to manage finances or seek employment, as well as connecting them to support services in the community.
Mutual Help Groups
In a support group, members provide each other with various types of help, usually nonprofessional and nonmaterial, for a particular shared, usually burdensome, characteristic. Members with the same issues can come together for sharing coping strategies, to feel more empowered, and for a sense of community. The help may take the form of providing and evaluating relevant information, relating personal experiences, listening to and accepting others’ experiences, providing sympathetic understanding and establishing social networks. A support group may also work to inform the public or engage in advocacy.
Membership in some support groups is formally controlled with admission requirements and membership fees. Other groups are open and allow anyone to attend an advertised meeting, for example, or to participate in an online forum.
A self-help support group is fully organized and managed by its members, who are commonly volunteers and have personal experience in the subject of the group’s focus. These groups may also be referred to as fellowships, peer support groups, lay organizations, mutual help groups, or mutual aid self-help groups. Most common are 12-step groups such as Alcoholics Anonymous and self-help groups for mental health. Alcoholic Anonymous (AA), is a voluntary program for people with alcoholism/AUD, based on belief on a spiritual basis for recovery. Members attend meeting and experiences are shared and “Twelve steps towards Recovery” are discussed. Avoiding alcohol and benefits of avoiding alcohol are discussed. Abstinence is encouraged on a daily or weekly basis.
Ecological systems theory and Addiction
Drug abuse and addiction are complex issues caused by individual factors, as well as community influences. For example, if a person grows up in an environment with exposure to illicit drugs, they may be more likely to abuse drugs. It is important to understand the interplay between an individual suffering from a drug addiction and their communities and other outside influences, including their relationships, and culture. Ecological systems theory, or the ecological/systems framework, developed by Urie Bronfenbrenner offers a framework through which community psychologists examine individuals’ relationships within communities and the wider society. The theory is also commonly referred to as the ecological/systems framework. It identifies five environmental systems with which an individual interacts. Consider ways in which these systems influence addiction, and how they might all be taken into account during rehabilitation efforts.
- Microsystem refers to the institutions and groups that most immediately and directly impact the a person’s development including family, school, religious institutions, neighborhood, and peers.
- Mesosystem consists of interconnections between the microsystems, for example between the family and teachers or between a person’s peers and the family.
- Exosystem involves links between social settings that do not involve the individual. For example, a child’s experience at home may be influenced by their parent’s experiences at work. A parent might receive a promotion that requires more travel, which in turn increases conflict with the other parent resulting in changes in their patterns of interaction with the child.
- Macrosystem describes the overarching culture that influences the developing person, as well as the microsystems and mesosystems embedded in those cultures. Cultural contexts can differ based on geographic location, SES, poverty, and ethnicity. Members of a cultural group often share a common identity, heritage, and values. Macrosystems evolve across time and from generation to generation.
- Chronosystem consists of the pattern of environmental events and transitions over the life course, as well as changing socio-historical circumstances. For example, researchers have found that the negative effects of divorce on children often peak in the first year after the divorce. By two years after the divorce, family interaction is less chaotic and more stable. An example of changing sociohistorical circumstances is the increase in opportunities for women to pursue a career during the last thirty years.
This video highlights some effective treatment options for substance use disorders.
You can view the transcript for “Substance Use Treatment” here (opens in new window).
- Heyman GM (2013) Addiction and choice: theory and new data. Front. Psychiatry 4:31. doi: 10.3389/fpsyt.2013.00031 ↵