Treatment Programs
Agonist Maintenance Treatment for opiate
addicts usually is conducted in outpatient
settings, often called methadone treatment
programs. These programs use a long-acting
synthetic opiate medication, usually
methadone or LAAM, administered orally for
a sustained period at a dosage sufficient
to prevent opiate withdrawal, block the
effects of illicit opiate use, and
decrease opiate craving. Patients
stabilized on adequate, sustained dosages
of methadone or LAAM can function
normally. They can hold jobs, avoid the
crime and violence of the street culture,
and reduce their exposure to HIV by
stopping or decreasing injection drug use
and drug-related high-risk sexual
behavior.
Patients stabilized on opiate agonists can
engage more readily in counseling and
other behavioral interventions essential
to recovery and rehabilitation. The best,
most effective opiate agonist maintenance
programs include individual and/or group
counseling, as well as provision of, or
referral to, other needed medical,
psychological, and social services.
Patients stabilized on adequate sustained
dosages of methadone or LAAM can function
normally.
Further Reading:
Ball, J.C., and Ross, A. The Effectiveness
of Methadone Treatment. New York:
Springer-Verlag, 1991.
Cooper, J.R. Ineffective use of
psychoactive drugs; Methadone treatment is
no exception. JAMA Jan 8; 267(2): 281-282,
1992.
Dole, V.P.; Nyswander, M.; and Kreek, M.J.
Narcotic Blockade. Archives of Internal
Medicine 118: 304-309, 1996.
Lowinson, J.H.; Payte, J.T.; Joseph, H.;
Marion, I.J.; and Dole, V.P. Methadone
Maintenance. In: Lowinson, J.H.; Ruiz, P.;
Millman, R.B.; and Langrod, J.G., eds.
Substance Abuse: A Comprehensive Textbook.
Baltimore, MD, Lippincott, Williams &
Wilkins, 1996, pp. 405-414.
McLellan, A.T.; Arndt, I.O.; Metzger,
D.S.; Woody, G.E.; and O'Brien, C.P. The
effects of psychosocial services in
substance abuse treatment. JAMA Apr 21;
269(15): 1953-1959, 1993.
Novick, D.M.; Joseph, J.; Croxson, T.S.,
et al. Absence of antibody to human
immunodeficiency virus in long-term,
socially rehabilitated methadone
maintenance patients. Archives of Internal
Medicine Jan; 150(1): 97-99, 1990.
Simpson, D.D.; Joe, G.W.; and Bracy, S.A.
Six-year follow-up of opioid addicts after
admission to treatment. Archives of
General Psychiatry Nov; 39(11): 1318-1323,
1982.
Simpson, D.D. Treatment for drug abuse;
Follow-up outcomes and length of time
spent. Archives of General Psychiatry
38(
: 875-880, 1981.
Narcotic Antagonist Treatment Using
Naltrexone for opiate addicts usually is
conducted in outpatient settings although
initiation of the medication often begins
after medical detoxification in a
residential setting. Naltrexone is a
long-acting synthetic opiate antagonist
with few side effects that is taken orally
either daily or three times a week for a
sustained period of time. Individuals must
be medically detoxified and opiate-free
for several days before naltrexone can be
taken to prevent precipitating an opiate
abstinence syndrome. When used this way,
all the effects of self-administered
opiates, including euphoria, are
completely blocked. The theory behind this
treatment is that the repeated lack of the
desired opiate effects, as well as the
perceived futility of using the opiate,
will gradually over time result in
breaking the habit of opiate addiction.
Naltrexone itself has no subjective
effects or potential for abuse and is not
addicting. Patient noncompliance is a
common problem. Therefore, a favorable
treatment outcome requires that there also
be a positive therapeutic relationship,
effective counseling or therapy, and
careful monitoring of medication
compliance.
Patients stabilized on naltrexone can hold
jobs, avoid crime and violence, and reduce
their exposure to HIV.
Many experienced clinicians have found
naltrexone most useful for highly
motivated, recently detoxified patients
who desire total abstinence because of
external circumstances, including impaired
professionals, parolees, probationers, and
prisoners in work-release status. Patients
stabilized on naltrexone can function
normally. They can hold jobs, avoid the
crime and violence of the street culture,
and reduce their exposure to HIV by
stopping injection drug use and
drug-related high-risk sexual behavior.
Further Reading:
Cornish, J.W.; Metzger, D.; Woody, G.E.;
Wilson, D.; McLellan, A.T.; Vandergrift,
B.; and O'Brien, C.P. Naltrexone
pharmacotherapy for opioid dependent
federal probationers. Journal of Substance
Abuse Treatment 14(6): 529-534, 1997.
Greenstein, R.A.; Arndt, I.C.; McLellan,
A.T.; and O'Brien, C.P. Naltrexone: a
clinical perspective. Journal of Clinical
Psychiatry 45 (9 Part 2): 25-28, 1984.
Resnick, R.B.; Schuyten-Resnick, E.; and
Washton, A.M. Narcotic antagonists in the
treatment of opioid dependence: review and
commentary. Comprehensive Psychiatry
20(2): 116-125, 1979.
Resnick, R.B. and Washton, A.M. Clinical
outcome with naltrexone: predictor
variables and followup status in
detoxified heroin addicts. Annals of the
New York Academy of Sciences 311: 241-246,
1978.
Outpatient Drug-Free Treatment in the
types and intensity of services offered.
Such treatment costs less than residential
or inpatient treatment and often is more
suitable for individuals who are employed
or who have extensive social supports.
Low-intensity programs may offer little
more than drug education and admonition.
Other outpatient models, such as intensive
day treatment, can be comparable to
residential programs in services and
effectiveness, depending on the individual
patient's characteristics and needs. In
many outpatient programs, group counseling
is emphasized. Some outpatient programs
are designed to treat patients who have
medical or mental health problems in
addition to their drug disorder.
Further Reading:
Higgins, S.T.; Budney, A.J.; Bickel, W.K.;
Foerg, F.E.; Donham, R.; and Badger, G.J.
Incentives to improve outcome in
outpatient behavioral treatment of cocaine
dependence. Archives of General Psychiatry
51, 568-576, 1994.
Hubbard, R.L.; Craddock, S.G.; Flynn,
P.M.; Anderson, J.; and Etheridge, R.M.
Overview of 1-year follow-up outcomes in
the Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors
11(4): 291-298, 1998.
Institute of Medicine. Treating Drug
Problems. Washington, D.C.: National
Academy Press, 1990.
McLellan, A.T.; Grisson, G.; Durell, J.;
Alterman, A.I.; Brill, P.; and O'Brien,
C.P. Substance abuse treatment in the
private setting: Are some programs more
effective than others? Journal of
Substance Abuse Treatment 10, 243-254,
1993.
Simpson, D.D. and Brown, B.S. Treatment
retention and follow-up outcomes in the
Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors
11(4): 294-307, 1998.
Long-Term Residential Treatment provides
care 24 hours per day, generally in
nonhospital settings. The best-known
residential treatment model is the
therapeutic community (TC), but
residential treatment may also employ
other models, such as cognitive-behavioral
therapy.
TCs are residential programs with planned
lengths of stay of 6 to 12 months. TCs
focus on the "resocialization" of the
individual and use the program's entire
"community," including other residents,
staff, and the social context, as active
components of treatment. Addiction is
viewed in the context of an individual's
social and psychological deficits, and
treatment focuses on developing personal
accountability and responsibility and
socially productive lives. Treatment is
highly structured and can at times be
confrontational, with activities designed
to help residents examine damaging
beliefs, self-concepts, and patterns of
behavior and to adopt new, more harmonious
and constructive ways to interact with
others. Many TCs are quite comprehensive
and can include employment training and
other support services on site.
Therapeutic communities focus on the
"resocialization" of the individual and
use the program's entire "community" as
active components of treatment.
Compared with patients in other forms of
drug treatment, the typical TC resident
has more severe problems, with more
co-occurring mental health problems and
more criminal involvement. Research shows
that TCs can be modified to treat
individuals with special needs, including
adolescents, women, those with severe
mental disorders, and individuals in the
criminal justice system (see Treating
Criminal Justice-Involved Drug Abusers and
Addicts ).
Further Reading:
Leukefeld, C.; Pickens, R.; and Schuster,
C.R. Improving drug abuse treatment:
Recommendations for research and practice.
In: Pickens, R.W.; Luekefeld, C.G.; and
Schuster, C.R., eds. Improving Drug Abuse
Treatment, National Institute on Drug
Abuse Research Monograph Series, DHHS Pub
No. (ADM) 91-1754, U.S. Government
Printing Office, 1991.
Lewis, B.F.; McCusker, J.; Hindin, R.;
Frost, R.; and Garfield, F. Four
residential drug treatment programs:
Project IMPACT. In: Inciardi, J.A.; Tims,
F.M.; and Fletcher, B.W. eds. Innovative
Approaches in the Treatment of Drug Abuse.
Westport, CN: Greenwood Press, 1993, pp.
45-60.
Sacks, S.; Sacks, J.; DeLeon, G.;
Bernhardt, A.; and Staines, G. Modified
therapeutic community for mentally ill
chemical abusers: Background; influences;
program description; preliminary findings.
Substance Use and Misuse 32(9); 1217-1259,
1998.
Stevens, S.J., and Glider, P.J.
Therapeutic communities: Substance abuse
treatment for women. In: Tims, F.M.; De
Leon, G.; and Jainchill, N., eds.
Therapeutic Community: Advances in
Research and Application, National
Institute on Drug Abuse Research Monograph
144, NIH Pub. No. 94-3633, U.S. Government
Printing Office, 1994, pp. 162-180.
Stevens, S.; Arbiter, N.; and Glider, P.
Women residents: Expanding their role to
increase treatment effectiveness in
substance abuse programs. International
Journal of the Addictions 24(5): 425-434,
1989.
Short-Term Residential Programs provide
intensive but relatively brief residential
treatment based on a modified 12-step
approach. These programs were originally
designed to treat alcohol problems, but
during the cocaine epidemic of the
mid-1980's, many began to treat illicit
drug abuse and addiction. The original
residential treatment model consisted of a
3 to 6 week hospital-based inpatient
treatment phase followed by extended
outpatient therapy and participation in a
self-help group, such as Alcoholics
Anonymous. Reduced health care coverage
for substance abuse treatment has resulted
in a diminished number of these programs,
and the average length of stay under
managed care review is much shorter than
in early programs.
Further Reading:
Hubbard, R.L.; Craddock, S.G.; Flynn,
P.M.; Anderson, J.; and Etheridge, R.M.
Overview of 1-year follow-up outcomes in
the Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors
11(4): 291-298, 1998.
Miller, M.M. Traditional approaches to the
treatment of addiction. In: Graham A.W.
and Schultz T.K., eds. Principles of
Addiction Medicine, 2nd ed. Washington,
D.C.: American Society of Addiction
Medicine, 1998.
Medical Detoxification is a process
whereby individuals are systematically
withdrawn from addicting drugs in an
inpatient or outpatient setting, typically
under the care of a physician.
Detoxification is sometimes called a
distinct treatment modality but is more
appropriately considered a precursor of
treatment, because it is designed to treat
the acute physiological effects of
stopping drug use. Medications are
available for detoxification from opiates,
nicotine, benzodiazepines, alcohol,
barbiturates, and other sedatives. In some
cases, particularly for the last three
types of drugs, detoxification may be a
medical necessity, and untreated
withdrawal may be medically dangerous or
even fatal.
Detoxification is a precursor of
treatment.
Detoxification is not designed to address
the psychological, social, and behavioral
problems associated with addiction and
therefore does not typically produce
lasting behavioral changes necessary for
recovery. Detoxification is most useful
when it incorporates formal processes of
assessment and referral to subsequent drug
addiction treatment.
Further Reading:
Kleber, H.D. Outpatient detoxification
from opiates. Primary Psychiatry 1: 42-52,
1996.
Treating Criminal Justice-Involved Drug
Abusers and Addicts
Research has shown that combining criminal
justice sanctions with drug treatment can
be effective in decreasing drug use and
related crime. Individuals under legal
coercion tend to stay in treatment for a
longer period of time and do as well as or
better than others not under legal
pressure. Often, drug abusers come into
contact with the criminal justice system
earlier than other health or social
systems, and intervention by the criminal
justice system to engage the individual in
treatment may help interrupt and shorten a
career of drug use. Treatment for the
criminal justice-involved drug abuser or
drug addict may be delivered prior to,
during, after, or in lieu of
incarceration.
Combining criminal justice sanctions with
drug treatment can be effective in
decreasing drug use and related crime.
Prison-Based Treatment Programs
Offenders with drug disorders may
encounter a number of treatment options
while incarcerated, including didactic
drug education classes, self-help
programs, and treatment based on
therapeutic community or residential
milieu therapy models. The TC model has
been studied extensively and can be quite
effective in reducing drug use and
recidivism to criminal behavior. Those in
treatment should be segregated from the
general prison population, so that the
"prison culture" does not overwhelm
progress toward recovery. As might be
expected, treatment gains can be lost if
inmates are returned to the general prison
population after treatment. Research shows
that relapse to drug use and recidivism to
crime are significantly lower if the drug
offender continues treatment after
returning to the community.
Community-Based Treatment for Criminal
Justice Populations
A number of criminal justice alternatives
to incarceration have been tried with
offenders who have drug disorders,
including limited diversion programs,
pretrial release conditional on entry into
treatment, and conditional probation with
sanctions. The drug court is a promising
approach. Drug courts mandate and arrange
for drug addiction treatment, actively
monitor progress in treatment, and arrange
for other services to drug-involved
offenders. Federal support for planning,
implementation, and enhancement of drug
courts is provided under the U.S.
Department of Justice Drug Courts Program
Office.
As a well-studied example, the Treatment
Accountability and Safer Communities
(TASC) program provides an alternative to
incarceration by addressing the multiple
needs of drug-addicted offenders in a
community-based setting. TASC programs
typically include counseling, medical
care, parenting instruction, family
counseling, school and job training, and
legal and employment services. The key
features of TASC include (1) coordination
of criminal justice and drug treatment;
(2) early identification, assessment, and
referral of drug-involved offenders; (3)
monitoring offenders through drug testing;
and (4) use of legal sanctions as
inducements to remain in treatment.
Further Reading:
Anglin, M.D. and Hser, Y. Treatment of
drug abuse. In: Tonry M. and Wilson J.Q.,
eds. Drugs and crime. Chicago: University
of Chicago Press, 1990, pp. 393-460.
Hiller, M.L.; Knight, K.; Broome, K.M.;
and Simpson, D.D. Compulsory
community-based substance abuse treatment
and the mentally ill criminal offender.
The Prison Journal 76(2), 180-191, 1996.
Hubbard, R.L.; Collins, J.J.; Rachal,
J.V.; and Cavanaugh, E.R. The criminal
justice client in drug abuse treatment. In
Leukefeld C.G. and Tims F.M., eds.
Compulsory treatment of drug abuse:
Research and clinical practice [NIDA
Research Monograph 86]. Washington, DC:
U.S. Government Printing Office, 1998.
Inciardi, J.A.; Martin, S.S.; Butzin,
C.A.; Hooper, R.M.; and Harrison, L.D. An
effective model of prison-based treatment
for drug-involved offenders. Journal of
Drug Issues 27 (2): 261-278, 1997.
Wexler, H.K. The success of therapeutic
communities for substance abusers in
American prisons. Journal of Psychoactive
Drugs 27(1): 57-66, 1997.
Wexler, H.K. Therapeutic communities in
American prisons. In Cullen, E.; Jones,
L.; and Woodward R., eds. Therapeutic
Communities in American Prisons. New York:
Wiley and Sons, 1997.
Wexler, H.K.; Falkin, G.P.; and Lipton,
D.S. (1990). Outcome evaluation of a
prison therapeutic community for substance
abuse treatment. Criminal Justice and
Behavior 17(1): 71-92, 1990.
Scientifically Based Approches to Drug
Addiction Treatment
This section presents several examples of
treatment approaches and components that
have been developed and tested for
efficacy through research supported by the
National Institute on Drug Abuse (NIDA).
Each approach is designed to address
certain aspects of drug addiction and its
consequences for the individual, family,
and society. The approaches are to be used
to supplement or enhanceÑnot
replaceÑexisting treatment programs.
This section is not a complete list of
efficacious, scientifically based
treatment approaches. Additional
approaches are under development as part
of NIDA's continuing support of treatment
research.
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Relapse Prevention, a cognitive-behavioral
therapy, was developed for the treatment
of problem drinking and adapted later for
cocaine addicts. Cognitive-behavioral
strategies are based on the theory that
learning processes play a critical role in
the development of maladaptive behavioral
patterns. Individuals learn to identify
and correct problematic behaviors. Relapse
prevention encompasses several
cognitive-behavioral strategies that
facilitate abstinence as well as provide
help for people who experience relapse.
The relapse prevention approach to the
treatment of cocaine addiction consists of
a collection of strategies intended to
enhance self-control. Specific techniques
include exploring the positive and
negative consequences of continued use,
self-monitoring to recognize drug cravings
early on and to identify high-risk
situations for use, and developing
strategies for coping with and avoiding
high-risk situations and the desire to
use. A central element of this treatment
is anticipating the problems patients are
likely to meet and helping them develop
effective coping strategies.
Research indicates that the skills
individuals learn through relapse
prevention therapy remain after the
completion of treatment. In one study,
most people receiving this
cognitive-behavioral approach maintained
the gains they made in treatment
throughout the year following treatment.
References:
Carroll, K.; Rounsaville, B.; and Keller,
D. Relapse prevention strategies for the
treatment of cocaine abuse. American
Journal of Drug and Alcohol Abuse 17(3):
249-265, 1991.
Carroll, K.; Rounsaville, B.; Nich, C.;
Gordon, L.; Wirtz, P.; and Gawin, F.
One-year follow-up of psychotherapy and
pharmacotherapy for cocaine dependence:
delayed emergence of psychotherapy
effects. Archives of General Psychiatry
51: 989-997, 1994.
Marlatt, G. and Gordon, J.R., eds. Relapse
Prevention: Maintenance Strategies in the
Treatment of Addictive Behaviors. New
York: Guilford Press, 1985.
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The Matrix Model provides a framework for
engaging stimulant abusers in treatment
and helping them achieve abstinence.
Patients learn about issues critical to
addiction and relapse, receive direction
and support from a trained therapist,
become familiar with self-help programs,
and are monitored for drug use by urine
testing. The program includes education
for family members affected by the
addiction.
The therapist functions simultaneously as
teacher and coach, fostering a positive,
encouraging relationship with the patient
and using that relationship to reinforce
positive behavior change. The interaction
between the therapist and the patient is
realistic and direct but not
confrontational or parental. Therapists
are trained to conduct treatment sessions
in a way that promotes the patient's
self-esteem, dignity, and self-worth. A
positive relationship between patient and
therapist is a critical element for
patient retention.
Treatment materials draw heavily on other
tested treatment approaches. Thus, this
approach includes elements pertaining to
the areas of relapse prevention, family
and group therapies, drug education, and
self-help participation. Detailed
treatment manuals contain work sheets for
individual sessions; other components
include family educational groups, early
recovery skills groups, relapse prevention
groups, conjoint sessions, urine tests,
12-step programs, relapse analysis, and
social support groups.
A number of projects have demonstrated
that participants treated with the Matrix
model demonstrate statistically
significant reductions in drug and alcohol
use, improvements in psychological
indicators, and reduced risky sexual
behaviors associated with HIV
transmission. These reports, along with
evidence suggesting comparable treatment
response for methamphetamine users and
cocaine users and demonstrated efficacy in
enhancing naltrexone treatment of opiate
addicts, provide a body of empirical
support for the use of the model.
References:
Huber, A.; Ling, W.; Shoptaw, S.; Gulati,
V.; Brethen, P.; and Rawson, R.
Integrating treatments for methamphetamine
abuse: A psychosocial perspective. Journal
of Addictive Diseases 16: 41-50, 1997.
Rawson, R.; Shoptaw, S.; Obert, J.L.;
McCann, M.; Hasson, A.; Marinelli-Casey,
P.; Brethen, P.; and Ling, W. An intensive
outpatient approach for cocaine abuse: The
Matrix model. Journal of Substance Abuse
Treatment 12(2): 117-127, 1995.
