Principles of Addiction Treatment

The National Institute on Drug Abuse states: Drug treatment is intended to help addicted individuals stop compulsive drug seeking and use. Treatment can occur in a variety of settings, take many different forms, and last for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment is usually not sufficient. For many, treatment is a long-term process that involves multiple interventions and regular monitoring.

Principles of Effective Treatment  

grugabuse.gov   Principles of Drug Addiction Treatment:  A Research Based Guide (Third Edition)

 

  1. Addiction is a complex but treatable disease that affects brain function and behavior.  Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences.  This is probably the most important piece to understand- so many factors are involved with addiction and alcoholism, including time (how long have they been using). frequency of use, amount and type(s) of drugs used.  Many family and friends who are assisting a person find treatment may not know or understand the combinations of drugs used or the frequency and amounts.  In addition, street drugs can be a combination that the user doesn’t even know.  For instance, Kratom is currently sold legally in most states, but it is not regulated and may be mixed with Fentanyl, salts, or other drugs.  

  2. No single treatment is appropriate for everyone.  Treatment varies depending on the type of drug and the characteristics of the patients. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.  Another huge factor here –  the elephant in the room – is the cost.  In today’s society, many people do not have commercial insurance, and Medicaid is not widely accepted outside of Detox- and Detox IS NOT treatment.  On average, a 30 day residential treatment program can cost 20,000 .00 and up.  If medications or longer detoxes are involved, the cost escalates.  Addiction has a high relapse rate and there is no guarantee.  

  3. Treatment needs to be readily available.  Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.  National incentives and awareness has greatly improved access to care; with that has come long waiting lists for medicaid treatment facilities.  In addition, there may be health or severe behavioral problems that will block this path.  Many residential detox facilities can delay services of there are indications of physical dangers to the patients (prospective severity of withdrawal, heart, liver or kidney damages severe abscesses, etc,) or behavioral (combative, suicidal, eating disorders, etc)  

  4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.  To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture.  Residential facilities must meet state and federal guidelines for practice; most states also now require that they are accredited through a national association, such as CARF.  Ask facilities you interview if they are accredited and by whom.  When a program or service is CARF-accredited, it means the organization has passed an in-depth review and meets rigorous CARF guidelines for service and quality—a qualified endorsement that it conforms to internationally-recognized service standards and is focused on delivering the most favorable results for the patients.  http://www.carf.org/Accreditation

  5.  Remaining in treatment for an adequate period of time is critical.  The appropriate duration for an individual depends on the type and degree of the patient’s problems and needs. Most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer duration’s of treatment. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.  There are several schools of thought with the recommendation for long term treatment and repeated relapses.  Most commercial insurances will allow services if clinically significant, including mental health evaluations, but the majority will end in-patient services after 30 days.  Medicaid services in a non profit facility, if clinically significant, can extend for longer periods of time, including housing, work programs, etc.  The majority of patients who leave treatment prematurely have complained  their withdrawal symptoms Are overwhelming.  Post Acute Withdrawal Syndrome are symptoms that can occur during a prolonged period of withdrawal from substances. These symptoms aren’t comfortable – and include mood swings, irritability, tiredness, anxiety and more. They often result in emotional outbursts – tears, anger, even violence.  https://www.mayoclinic.org/   

    Other patients cited many obstacles, including family, employment and school.  Financial issues create a huge barrier.  The Mayo Clinic did a study and found that 17% of people who enter rehab for substance abuse or mental health issues will leave treatment prematurely. 

  6. Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment.   Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence.  Patients who enter into detox only will not receive the benefits of behavioral therapies, and out patient facilities aside from a Medication Assisted Treatment program are woefully difficult to find.  Many residential programs offer outpatient services for their patients who have completed detox and residential and accept patients who have not, on the condition they are able to remain abstinent.  Some of these facilities utilize the in-patient agendas for their group outpatients, which is repetitive to patients leaving residential, or are too advanced for those who have not engaged with in-patient.  Interview the potential out patient facility and request their group schedule.  Individual counseling and treatment planning should also be a major component; ask the facility how much time will be spent with the patient outside of the group setting to address their individual needs.   

  7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.  For example, methadone, buprenorphine, and naltrexone (including a new long-acting formulation) are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Acamprosate, disulfiram, and naltrexone are medications approved for treating alcohol dependence. Unfortunately, some outpatient facilities will not allow a patient to be on any medications while they are in outpatient treatment if they did not prescribe those medications in a detox or residential setting.  Methadone patients, as part of their medically managed treatment, are provided with outpatient counseling services; in fact, it is a federal requirement.  Buprenorphine or suboxone is less regulated, but  be sure to ask the facility.  Benzodiazepine use, due to it’s high abuse in the community, may need special permission if prescribed.  

  8. 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.  A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person’s changing needs.  Many of these services are considered ‘Case Management’ or ‘Peer Coaches’ and should be a component of outpatient services.  Ask the facility if you may meet with the Case Manager or recovery/peer coach.  Ask to see their referral reference books if possible, and ask how often they meet with the patient and how the services are provided.  

  9. Many drug-addicted individuals also have other mental disorders.  Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.  Many signs and symptoms of drug use can mimic mental illnesses and vice-versa. One may  create or emphasize the other, and there is a high comorbidity between addiction and mental health.  When the addiction is influenced or compounded by the use or mis-use of prescription drugs, many detox facilities choose to not provide any or limited prescription medications, which can negatively effect the withdrawal.  Today, more and more detox facilities are employing psychiatric care medical providers in their facilities to meet this need.  Patients will very rarely be allowed to bring medications with them into a facility; they will be ordered by the facility medical professionals if they choose to prescribe.  Some residential and detox facilities may be in isolated locations and ordering certain medications may be difficult; be sure to approach this when choosing a facility.  

    https://www.drugabuse.gov/

  10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.  Although medically assisted detoxification can safely manage the acute physical symptoms of withdrawal and can, for some, pave the way for effective long-term addiction treatment, detoxification alone is rarely sufficient to help addicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment following detoxification. Motivational enhancement and incentive strategies, begun at initial patient intake, can improve treatment engagement.  All detox facilities are required to provide each patient with referrals prior to leaving the facility.  They should be meeting with the patient and preparing a written and detailed plan.  Ask to meet with their Case Manager or Peer Support Specialist and ask how this service is provided, including how often they meet and how they will be connected to these services.  Ask to see their referral books.  Many times, patients are medicated through their withdrawal and have limited self resources to remember or participate in their own planning.  

  11. Treatment does not need to be voluntary to be effective.  Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.  There are numerous studies to support this theory, but there are times that patients may agree to conditions based upon their hopes that the consequences of their  actions stop.  If you or others plan an intervention, it is wise to have trained professionals to assist in the planning and execution.  In the event a person agrees to enter treatment, it should be available immediately upon agreeing.  This takes careful planning and coordination, plus extensive meetings with the loved ones.  The greatest failure of an intervention is not the patient refusing-it is the participants who waffle on the conditions that collapse the system.  Contact a reputable treatment facility for a recommendation, ask at Al-Anon or Nar-Anon meetings, or hospitals.                                                                   https://family-intervention.com/directory/intervention/

  12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur.  Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs.  Many loved ones feel the need to use urine drug screen tests available at local pharmacies.  These are not conclusive nor are they absolutely accurate.  Reputable facilities will utilize a toxicology service that will use a two step method for validating any positive screen, which would be acceptable in a court of law.   Urine drug screens can be falsified , however, and some drugs will not appear.  At this time, not all facilities are testing for Kratom, and Fentanyl is still in the process of being tested wide spread.  Drug screens are a useful tool, but daily contact and behavior monitoring are still reliable.  Remember-In early recovery, or in the instance of a new medication or medication assisted treatment, it is normal for the patient to be tired and sleep.  Consult a medical professional for your concerns.  

  13. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.   Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can 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 likelihood that patients will be tested and receive their test results. Treatment providers should also inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drug-abusing populations, and help link them to HIV treatment if they test positive.  At this time, any patient entering an MAT (medication assisted  treatment) or detox/residential facility will be tested.  Ask the facility how that test is conducted, how the results will be delivered,  Most patients with Medicaid will be provided with Hep C treatment, although they may be told that their ‘Hep C isn’t bad enough to treat’.  In this event, or if the provider refuses because the patient is continuing to use or has recent use, contact your states health authority for assistance.  There should be no barriers to treatment.  

 

Medication Assisted Treatment Information

Treatment medications, such as methadone, buprenorphine, and naltrexone (including a new long-acting formulation), are available for individuals addicted to opioids. Methadone treatment has been shown to increase participation in behavioral therapy and decrease both drug use and criminal behavior. However, individual treatment outcomes depend on the extent and nature of the patient’s problems.

Acamprosate, and naltrexone are medications available for treating alcohol dependence, which commonly co-occurs with other drug addictions, including addiction to prescription medications.

Treatments for prescription drug abuse tend to be similar to those for illicit drugs that affect the same brain systems. For example, buprenorphine used to treat heroin addiction, can also be used to treat addiction to opioid pain medications. Addiction to prescription stimulants, which affect the same brain systems as illicit stimulants like cocaine, can be treated with behavioral therapies, as there are not yet medications for treating addiction to these types of drugs.

Finally, people who are addicted to drugs often suffer from other health (e.g., depression, HIV), occupational, legal, familial, and social problems that should be addressed concurrently. The best programs provide a combination of therapies and other services to meet an individual patient’s needs. Psychoactive medications, such as antidepressants, anti-anxiety agents, mood stabilizers, and antipsychotic medications, may be critical for treatment success when patients have co-occurring mental disorders such as depression, anxiety disorders (including post-traumatic stress disorder), bipolar disorder, or schizophrenia. In addition, most people with severe addiction abuse multiple drugs and require treatment for all substances abused.

Opioid Addiction

Some people think that medications like methadone and buprenorphine simply replacing one addiction with another. This is not true.

  • Buprenorphine and methadone are prescribed or administered under monitored, controlled conditions and are safe and effective for treating opioid addiction when used as directed. They are administered orally or sublingually (i.e., under the tongue) in specified doses, and their effects differ from those of heroin and other abused opioids.
  • Heroin, for example, is often injected, snorted, or smoked, causing an almost immediate “rush,” or brief period of intense euphoria, that wears off quickly and ends in a “crash.” The individual then experiences an intense craving to use the drug again to stop the crash and reinstate the euphoria.
  • The cycle of euphoria, crash, and craving—sometimes repeated several times a day—is a hallmark of addiction and results in severe behavioral disruption. These characteristics result from heroin’s rapid onset and short duration of action in the brain.
  • As used in maintenance treatment, methadone and buprenorphine are not heroin/opioid substitutes.
  • In contrast, methadone and buprenorphine have gradual onsets of action and produce stable levels of the drug in the brain. As a result, patients maintained on these medications do not experience a rush, while they also markedly reduce their desire to use opioids.
  • If an individual treated with these medications tries to take an opioid such as heroin, the euphoric effects are usually dampened or suppressed. Patients undergoing maintenance treatment do not experience physiological or behavioral abnormalities from rapid fluctuations in drug levels associated with heroin use. Maintenance treatments save lives—they help to stabilize individuals, allowing treatment of their medical, psychological, and other problems so they can contribute effectively as members of families and of society.Methadone for
  • Methadone for Heroin Addiction  –  For many people, tolerance for opiates has increased to a point that Suboxone or Buprenorphine treatment does not provide relief from symptoms of withdrawal.  One of the reasons that these two treatments are provided with greater access through medical doctors or at a lower level of regulation is their safety of use.  Methadone is able to be prescribed in higher doses to meet those greater withdrawal symptoms.  It is heavily regulated due to its lethal potential when used with other substances (such as  Alcohol or Benzodiazepines)
  • Methadone is a long-acting synthetic opioid agonist medication that can prevent withdrawal symptoms and reduce craving in opioid-addicted individuals. It can also block the effects of illicit opioids. It has a long history of use in the treatment of opioid dependence in adults and is taken orally. Methadone maintenance treatment is available in all but three States through specially licensed opioid treatment programs or methadone maintenance programs.
  • Combined with behavioral treatment: Research has shown that methadone maintenance is more effective when it includes individual and/or group counseling, with even better outcomes when patients are provided with, or referred to, other needed medical/psychiatric, psychological, and social services (e.g., employment or family services).

Practical Knowledge:

Opiate use disorders are epidemic in our world and present with a plethora of problems. If the patient was treated for pain and prescribed prescription pain medications which was a precursor to their addiction, the pain issues will not go away with treatment for addiction. Medication Assisted Treatment is a good option.
Here is a scenario-A suburban homemaker suffers from endometriosis and is prescribed pain medications. As her use continues and pain intensifies, she may find her self using more of the prescription(this is tolerance). At some point, her doctor becomes alarmed at her increasing requests for medications and may stop or reduce her prescription. Now, she still has the same pain, but has added withdrawal symptoms to that. She still needs to function in her role as a mother and support, so she asks around and finds someone who is willing to sell her their prescription. The cycle increases, the pills get harder to find and increasingly expensive, and someone introduces her to Heroin. Guess what. It is in the suburbs. Where will she find treatment? Her pain is very real, intensified by use, combined with a very wicked withdrawal, and now add the stigma of addiction.
Most residential detox facilities will assist with detox, and may prescribe Suboxone or Buprenorphine to assist with the symptoms of withdrawal, but for a person with a high tolerance for opioids, those medications may not be adequate. Buprenorphine or Suboxone have about a 10% opiate concentrate, while Methadone contains around 30%. Only hospitals or an approved and licensed MAT provider can prescribe Methadone, and she will be medically monitored daily, which means she will need to present daily for her medication. Over time, as patients display responsibility for treatment (not skipping doses, not using other drugs, engagement in counseling), they will gain the right to unsupervised dosing and take-home medication privileges. (See the link below for locations throughout the U.S.). The average MAT program is 2-4 years, tapering slowly off to avoid symptoms of withdrawal. Using other pain narcotics while on a methadone management program is usually not an option.

Buprenorphine
Buprenorphine is a synthetic opioid medication that acts as a partial agonist at opioid receptors—it does not produce the euphoria and sedation caused by heroin or other opioids but is able to reduce or eliminate withdrawal symptoms associated with opioid dependence and carries a low risk of overdose.

Buprenorphine is currently available in two formulations that are taken sublingually: (1) a pure form of the drug and (2) a more commonly prescribed formulation called Suboxone, which combines buprenorphine with the drug naloxone, an antagonist (or blocker) at opioid receptors. Naloxone has no effect when Suboxone is taken as prescribed, but if an addicted individual attempt to inject Suboxone, the naloxone will produce severe withdrawal symptoms. Thus, this formulation lessens the likelihood that the drug will be abused or diverted to others.

Buprenorphine treatment for detoxification and/or maintenance can be provided in office-based settings by qualified physicians who have received a waiver from the Drug Enforcement Administration (DEA), allowing them to prescribe it. The availability of office-based treatment for opioid addiction is a cost-effective approach that increases the reach of treatment and the options available to patients.

Buprenorphine is also available as in an implant and injection. The U.S. Food and Drug Administration (FDA) approved a 6-month subdermal buprenorphine implant in May 2016 and a once-monthly buprenorphine injection in November 2017.

Treatment, not Substitution
Because methadone and buprenorphine are themselves opioids, some people view these treatments for opioid dependence as just substitutions of one addictive drug for another  But taking these medications as prescribed allows patients to hold jobs, avoid street crime and violence, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. Patients stabilized on these medications can also engage more readily in counseling and other behavioral interventions essential to recovery.

Naltrexone
Naltrexone is a synthetic opioid antagonist—it blocks opioids from binding to their receptors and thereby prevents their euphoric and other effects. It has been used for many years to reverse opioid overdose and is also approved for treating opioid addiction. The theory behind this treatment is that the repeated absence of the desired effects and the perceived futility of abusing opioids will gradually diminish craving and addiction. Naltrexone itself has no subjective effects following detoxification (that is, a person does not perceive any particular drug effect), it has no potential for abuse, and it is not addictive.

Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although the treatment should begin after medical detoxification in a residential setting in order to prevent withdrawal symptoms.

Naltrexone must be taken orally—either daily or three times a week—but noncompliance with treatment is a common problem. Many experienced clinicians have found naltrexone best suited for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances—for instance, professionals or parolees. Recently, a long-acting injectable version of naltrexone, called Vivitrol, was approved to treat opioid addiction. Because it only needs to be delivered once a month, this version of the drug can facilitate compliance and offers an alternative for those who do not wish to be placed on agonist/partial agonist medications.

Alcohol Addiction
Naltrexone
Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. It has been shown to reduce relapse to problem drinking in some patients. An extended-release version, Vivitrol—administered once a month by injection—is also FDA-approved for treating alcoholism, and may offer benefits regarding compliance.

Acamprosate
Acamprosate (Campral®) acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria. Acamprosate has been shown to help dependent drinkers maintain abstinence for several weeks to months, and it may be more effective in patients with severe dependence.

Disulfiram
Disulfiram (Antabuse®) interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if a person drinks alcohol. The utility and effectiveness of disulfiram are considered limited because compliance is generally poor. However, among patients who are highly motivated, disulfiram can be effective, and some patients use it episodically for high-risk situations, such as social occasions where alcohol is present. It can also be administered in a monitored fashion, such as in a clinic or by a spouse, improving its efficacy.

Topiramate
Topiramate is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission, although its precise mechanism of action is not known. Although topiramate has not yet received FDA approval for treating alcohol addiction, it is sometimes used off-label for this purpose. Topiramate has been shown in studies to significantly improve multiple drinking outcomes, compared with a placebo.

Combined With Behavioral Treatment
While a number of behavioral treatments have been shown to be effective in the treatment of alcohol addiction, it does not appear that an additive effect exists between behavioral treatments and pharmacotherapy. Studies have shown that just getting help is one of the most important factors in treating alcohol addiction; the precise type of treatment received is not as important.

https://www.drugabuse.gov/publications/principles-drug-addiction-treatment

Numerous online resources can help locate a local program or provide other information, including:

  • The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a Web site (findtreatment.gov) that shows the location of residential, outpatient, and hospital inpatient treatment programs for drug addiction and alcoholism throughout the country. This information is also accessible by calling 1-800-662-HELP.

  • The National Suicide Prevention Lifeline (1-800-273-TALK) offers more than just suicide prevention—it can also help with a host of issues, including drug and alcohol abuse, and can connect individuals with a nearby professional.

  • The National Alliance on Mental Illness  (  https://www.nami.org/Home  )   and Mental Health America  (  https://mhanational.org/  )   are alliances of nonprofit, self-help support organizations for patients and families dealing with a variety of mental disorders. Both have State and local affiliates throughout the country and may be especially helpful for patients with comorbid conditions.

  • The American Academy of Addiction Psychiatry and the American Academy of Child and Adolescent Psychiatry each have physician locator tools posted on their Web sites at aaap.org and aacap.org, respectively.

  • Faces & Voices of Recovery (facesandvoicesofrecovery.org), founded in 2001, is an advocacy organization for individuals in long-term recovery that have strategies on ways to reach out to the medical, public health, criminal justice, and other communities to promote and celebrate recovery from addiction to alcohol and other drugs.

  • The Partnership at Drugfree.org (drugfree.org) is an organization that provides information and resources on teen drug use and addiction for parents, to help them prevent and intervene in their children’s drug use or find treatment for a child who needs it. They offer a toll-free helpline for parents (1-855-378-4373).

  • The American Society of Addiction Medicine (asam.org) is a society of physicians aimed at increasing access to addiction treatment. Their Web site has a nationwide directory of addiction medicine professionals.

  • NIDA’s National Drug Abuse Treatment Clinical Trials Network (drugabuse.gov/about-nida/organization/cctn/ctn) provides information for those interested in participating in a clinical trial testing a promising substance abuse intervention; or visit clinicaltrials.gov.

  • NIDA’s DrugPubs Research Dissemination Center (drugpubs.drugabuse.gov) provides booklets, pamphlets, fact sheets, and other informational resources on drugs, drug abuse, and treatment.

  • The National Institute on Alcohol Abuse and Alcoholism (niaaa.nih.gov) provides information on alcohol, alcohol use, and treatment of alcohol-related problems (niaaa.nih.gov/search/node/treatment).

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