|TREATMENT OF SUBSTANCE USE DISORDERS
Treatment for substance abuse or dependence requires specialist care
from certified counselors or comprehensive community programs or mutual
help groups. You should understand the core principles of treatment,
so you can best advise your patients.
- Primary care physicians play a key role in identifying high-risk patients
and providing appropriate prevention counseling. When appropriate, family
members should be engaged as well.
- Primary care physicians also play an essential role in referring patients
for treatment. Convey to patients that substance use disorders are chronic,
relapsing diseases that can be successfully treated and managed and that
recovery is a long-term process.
- Effective treatment needs to be individualized, and it includes psychosocial
and pharmacological interventions.
- Treatment recommendations need to be staged based on patients’ immediate
treatment needs, e.g. brief intervention identifying the diagnoses for
the patient, detoxification to manage withdrawal symptoms, residential
or outpatient treatment, and 12-step programs.
- Initial and brief interventions include discussions of the results of
screening, advice about the need to change substance use behaviors, evaluation
of patients’ readiness to make change, negotiation of goals,
scheduling of follow-up visits and referral for specialized substance use
- Assessment and treatment for co-morbid psychiatric disorders
are essential components of substance abuse treatment.
- No single treatment is appropriate for all individuals. Matching
treatment settings, interventions, and services to each individual's
particular problems and needs is critical to his or her ultimate success
in returning to productive functioning in the family, workplace, and
- Treatment needs to be readily available. Because individuals
who are addicted to drugs may be uncertain about entering treatment,
taking advantage of opportunities when they are ready for treatment is
crucial. Potential treatment applicants can be lost if treatment is not
immediately available or is not readily accessible.
- Effective treatment attends to multiple needs of the individual,
not just his or her drug use. To be effective, treatment must
address the individual's drug use and any associated medical, psychological,
social, vocational, and legal problems.
- An individual's treatment and services plan must be assessed
continually and modified as necessary to ensure that the plan meets
the person's 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 at times may require medication, other medical services,
family therapy, parenting instruction, vocational rehabilitation, and
social and legal services. It is critical that the treatment approach
be appropriate to the individual's age, gender, ethnicity, and culture.
- Remaining in treatment for an adequate period of time is critical
for treatment effectiveness. The appropriate duration for
an individual depends on his or her problems and needs. Research indicates
that for most patients, the threshold of significant improvement is
reached at about 3 months in treatment. After this threshold is reached,
additional treatment can produce further progress toward recovery.
Because people often leave treatment prematurely, programs should include
strategies to engage and keep patients in treatment.
- Counseling (individual and/or group) and other behavioral therapies
are critical components of effective treatment for addiction. In
therapy, patients address issues of motivation, build skills to resist
drug use, replace drug-using activities with constructive and rewarding
non-drug-using activities, and improve problem-solving abilities. Behavioral
therapy also facilitates interpersonal relationships and the individual's
ability to function in the family and community.
- Medications are an important element of treatment for many
patients, especially when combined with counseling and other behavioral
therapies. Buprenorphine and methadone are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. (See also http://www.drugabuse.gov/drugpages/buprenorphine.html and http://www.drugabuse.gov/about/welcome/vivitrol1010.html). For patients with mental disorders, both behavioral treatments and medications can be critically important.
- Addicted or drug-abusing individuals with coexisting mental
disorders should have both disorders treated in an integrated way. Because
addictive disorders and mental disorders often occur in the same individual,
patients presenting for either condition should be assessed and treated
for the co-occurrence of the other type of disorder.
- Medical detoxification is only the first stage of addiction
treatment and by itself does little to change long-term drug use. Medical
detoxification safely manages the acute physical symptoms of withdrawal
associated with stopping drug use. While detoxification alone is rarely
sufficient to help addicts achieve long-term abstinence, for some individuals
it is a strongly indicated precursor to effective drug addiction treatment.
- Treatment does not need to be voluntary to be effective. Strong
motivation can facilitate the treatment process. Sanctions or enticements
in the family, employment setting, or criminal justice system can significantly
increase both treatment entry and retention rates and the success
of drug treatment interventions.
- Possible drug use during treatment must be monitored continuously. Lapses
to drug use can occur during treatment. The objective monitoring of a
patient's drug and alcohol use during treatment, such as through urinalysis
or other tests, can help the patient withstand urges to use drugs. Such
monitoring also can provide early evidence of drug use so that the individual's
treatment plan can be adjusted. Feedback to patients who test positive
for illicit drug use is an important element of monitoring.
- Treatment programs should provide assessment for HIV/AIDS, hepatitis
B and C, tuberculosis, and other infectious diseases; and counseling to
help patients modify or change behaviors that place themselves or others
at risk of infection. Counseling can help patients
avoid high-risk behavior. Counseling also can help people who are already
infected manage their illness.
- Recovery from drug addiction can be a long-term process and
frequently requires multiple episodes of treatment. As with
other chronic illnesses, relapses to drug use can occur during or after
successful treatment episodes. Addicted individuals may require prolonged
treatment and multiple episodes of treatment to achieve long-term abstinence
and fully restored functioning. Participation in self-help support
programs during and following treatment often is helpful in maintaining