What is Addiction Treatment?
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During 2000, almost 300,000 people entered addiction treatment services in New York State. On any given day, about 110,000 individuals are enrolled in New York State programs, which provide treatment for chemical abuse or chemical dependence. What does it mean to be in treatment? Does treatment work? Unfortunately, wide misconceptions exist regarding the nature and effectiveness of treatment for alcohol, opiates, cocaine, stimulants, nicotine, or other substances which people abuse. Given the continuously mounting evidence that treatment saves lives and money, it is possible to scientifically answer these important questions and bring clarity to many of the misconceptions that surround the alcohol and drug treatment field.
A Brief Overview of the Chemical Dependence Field
Like many health and human service fields, chemical dependence service delivery is continually evolving in response to new research and advances in practice. Recent scientific evidence finds that:
- Chemical addiction is a brain disease. Chronic exposure to alcohol and/or drugs changes the brain in fundamental and long lasting ways.
- Chemical dependence is a chronic, relapsing disease that requires changes in behavior for the individual. This places addiction in a category with heart disease, asthma, diabetes, and other chronic relapsing diseases.
- Addiction treatment is as effective in reducing the symptoms of the disease as are most treatments for heart disease, asthma and diabetes.
- Chemically dependent individuals comply with their treatment as frequently as those suffering from other chronic relapsing diseases, which require the individual to make permanent changes in their behaviors.
- While abstinence from chemicals is usually its goal, treatment success can also be seen in other documented outcomes (e.g., increased productivity and decreased criminal activity).
Treatment outcome evaluations are demonstrating which treatment techniques make the most difference in establishing and maintaining the gains of successful treatment for clients with addictions, and under what circumstances and for which populations those techniques are most effective. In its November 2001 monograph, Principles of Drug Addiction Treatment, the National Institute of Drug Abuse (NIDA) summarized the findings of several studies and indicated that drug treatment reduced drug use by 40 to 60 percent. NIDA also noted that criminal justice activity significantly decreased both during and after treatment. Treatment dramatically improved employment possibilities, with gains of up to 40 percent according to NIDA. They concluded that, "Treatment of addiction is as successful as treatment of other chronic diseases such as diabetes, hypertension and asthma."
An Evolving Field
The evolution in chemical dependence services can be found both in the design and organization of services and in the language describing the disease and its treatment. Less than ten years ago, New York State had separate systems of care - alcoholism prevention/treatment and substance abuse prevention/treatment. Each had discrete ways of describing their disorders and services. However, during the past ten years, the alcoholism and substance abuse systems have functionally merged, recognizing that many persons who abuse drugs also abuse alcohol. Programs now can serve the person's alcohol and drug problems more comprehensively. Gradually, terms like alcohol abuse, alcoholism, drug abuse, and substance abuse are being replaced by the terms, addiction, chemical abuse and chemical dependence. As will be described later, similar changes are now being reflected in the names used to identify services.
In addition, program services are beginning to reflect new models of service. Treatment models for women with children, specialized services for high-risk adolescents, and treatment programs for persons with both chemical dependence and mental illness are beginning to emerge in greater numbers. Similarly, prevention practice in New York State is being transformed by science and, consequently, public funds now support only evidence-based programs that have been proven by research to work.
As society more clearly recognizes the role of alcohol and drug abuse in contributing to problems such as crime, work-related accidents, lost productivity, and generally impaired judgment, many individuals are screened for alcohol and drug use as a condition of their employment or for public assistance benefits eligibility. Specifically, some people are given toxicology screenings, for which a positive result may lead to referrals for treatment. Some examples include blood alcohol tests administered to intoxicated drivers, urine screenings required as conditions of employment (e.g., pilots and interstate truckers) and toxicology screenings required of applicants for public welfare.
A positive result on a toxicology screen may lead to a formal assessment of the person's chemical abuse problem by a trained professional. This assessment would ascertain the nature and degree of the chemical abuse problem and determine whether there is a need for a referral for formal treatment. If treatment is required, an appropriate referral is made. Systematic toxicology screenings in certain occupations and for public assistance applicants ultimately save lives, lead to safer work environments, and have contributed to the nation's success with welfare reform.
Understanding Chemical Abuse and Dependence
Many people never use alcohol or other drugs; many others try a chemical but rarely experience any negative consequences. However, many people drink and/or use drugs problematically. Individuals who use a chemical and experience negative consequences are termed "chemical abusers." Some abusers are able to stop abusing by modifying their own behavior and using community supports, allowing them to eliminate the negative consequences. For those who are unable to effectively modify their behavior and whose use continues to be problematic, formal treatment interventions are recommended.
Chemical dependence is a complex disease. It is often characterized by compulsive - at times uncontrollable - craving, seeking and use that persists even in the face of extremely negative consequences. This disorder is a chronic condition with a high probability of relapse; it affects both the physical and mental health of the dependent individual. It also negatively affects interpersonal relationships with family members, significant others and/or friends of the addicted person. As such, the disease results in both physical and behavioral manifestations.
The addiction and resultant compulsion for alcohol or drugs can take over the individual's life, leading to a wide range of dysfunctional behaviors that interfere with family, workplace and broader community interactions. Many chemical dependent persons deny they have a problem, deceiving themselves and those close to them. They may show poor judgment, lack impulse control, and show marked mood swings. Persons with addiction can become preoccupied with alcohol or drugs and can be extremely careful in protecting their supply. Glamorizing the use of chemicals along with joyous memories of being "high" is also frequently associated with addiction.
The point at which an abuser becomes addicted is specific to that individual. Addiction is a chronic and progressive medical condition, with genetic, physical and behavioral components. It is similar to other chronic medical conditions such as hypertension, diabetes, and asthma, all of which can be treated effectively. Research has demonstrated that the relapse rates (40% - 60 percent) for those diseases is the same as for chemical dependency and equally dependent upon how patients comply with treatment recommendations.
Treatment of Addictive Disorders
Because chemical dependence is a complex disorder, effective treatment requires interventions that address the physical health, mental health, and interpersonal relationships of the affected individual. Therefore, the treatment process must be comprehensive and address the multiple and complex needs of addicted individuals and their families.
Essential elements of comprehensive treatment for addictive disorders consist of many components, some of which should be employed for every person and some only for certain individuals. To the extent possible, the individual's family should be engaged in part of the treatment process. The components include the following:
- Detoxification and medical management of withdrawal symptoms, if needed;
- a comprehensive evaluation of the nature of use, and strengths and needs of the individual which results in a diagnosis;
- an individualized treatment plan which is developed with the patient and is modified as the individual progresses;
- pharmacological therapy, when appropriate;
- monitoring of continued abstinence from alcohol and/or other substances;
- vocational and educational assistance;
- cognitive and behavioral therapy;
- clinical case management;
- continuing care; and
- self-help or peer support as a complement to professional treatment.
The evaluation, diagnosis and resulting treatment plan must be developed by qualified, experienced professionals in the addiction field, and must address the multiple aspects of the disease. Although addiction treatment provider need not provide all services directly, quality care then demands that services be planned for and provided through referral linkages with other appropriately qualified providers.
The treatment delivery process assures that all necessary and available services are delivered to address individuals' needs relating to addiction. Other issues that may be addressed in a comprehensive treatment process, in addition to addiction management, include physical health, mental health, strengthening the family, legal, financial, child care, housing, parenting, transportation, education, prevocational and work readiness. A quality process must include the availability of longer-term supports to sustain recovery and prevent relapse. Quality treatment also addresses public health concerns commonly associated with alcohol and substance abuse, including sexually transmitted diseases (STDs), hepatitis, HIV/AIDS and tuberculosis. Further, many providers now integrate treatment for nicotine dependence into chemical dependence programs.
The process of treatment begins with educating the individual and his or her family about the disease of addiction and assuring that each individual recognizes the signs and symptoms of the disease in his or her own life. Motivational enhancement may be the first step since many patients may not accept that their addiction is not normal. Teaching the individual to both recognize the triggers of relapse and use preventive responses to these triggers is critical during the treatment process. The outcome of appropriate, comprehensive treatment should strive toward helping the persons receiving services to accomplish the following:
- Understand the relevant issues associated with the disease as it affects their lives and the lives of those around them;
- Understand the physical impact of chemicals and the implications of addiction on brain functioning;
- Learn and practice the mechanisms, attitudes, skills and behaviors necessary to sustain the positive effects of treatment;
- Develop the capacity or potential to practice normal life activities with responsibility;
- Recognize the personal signs, symptoms, circumstances, and triggers of relapse and know how to respond; and
- Develop and sustain a social support network that will foster and reinforce ongoing recovery.
What happens during the treatment process?
Upon entering treatment, every person participates in a complete diagnostic evaluation leading to an individualized treatment plan. The evaluation and treatment plan are used to determine the types, level and intensity of services to be given to that individual and to manage the course of the treatment over time. (See the Appendix for 13 Principles of Effective Treatment taken from the National Institute on Drug Abuse.)
What happens during treatment to any one individual will, of course, be unique and specific to his or her personality and life circumstances. However, several typical treatment strategies may be offered singularly or in combination to patients. They include the following:
- Detoxification - Some persons have such a serious physical dependency that they may have to be carefully withdrawn from the addicting chemicals to address the potentially serious medical consequences of abruptly stopping usage. A physician often supervises this process. Because it does not treat the behavioral or psychosocial causes leading to the chemical dependence, detoxification often precedes involvement in behavioral treatment.
- Individual Therapy - Typically, individual patients will work with a professional therapist (e.g., counselor, social worker, psychologist) to understand the factors contributing to the compulsive abuses of alcohol and/or drugs, and to develop coping strategies to deal with the compulsions in order to cease the chemical abuse. When patients establish therapeutic trust with their counselors, strength is gained to learn about them, learn about their addiction, and learn new ways of living. Many therapeutic approaches exist. An ever-growing body of research is documenting which approaches work best for which populations (e.g., motivational enhancement therapy for adolescents, women).
- Group Therapy - Most chemical dependence treatment providers make professionally led group counseling or therapy a central part of treatment. By offering mutual support, these sessions allow participants to use the group format to share insights, reinforce member therapeutic gains, and to exert group accountability on individual behavior. Often, group therapy is provided to individuals who share some common experience or unresolved issue such as trauma survivors, gender specific focus, criminal justice involvement, parenting focus, etc.
- Pharmacological Therapy - Some patients receive medication - typically in combination with behavioral therapy - to help decrease the physical craving for chemicals. By relieving the symptoms, medications allow persons with addictions to participate more easily in other aspects of treatment. The most commonly used and best known of these medications is methadone, a medication given orally, which is highly effective in treating heroin and opiate addiction. Other medications currently used to treat chemical dependence include LAAM (l-alpha-acetyl-methadol), buperinorphine (soon to be approved), Antabuse, bupropion, and Naltrexone.
- Toxicology Screening and Monitoring - Most programs incorporate a process for monitoring the individual's continued abstinence from chemicals. Generally, this is accomplished through urine, blood and breath testing. For patients required to attend treatment by another system (e.g., court, child welfare, public assistance), reporting back to the judge or other identified official on the results of clients' toxicology tests will likely be a requisite component of the treatment regimen with client consent.
- Vocational Rehabilitation - Although many people in treatment programs are employed full time, many others enter treatment unemployed with few marketable skills. With the enactment of welfare reform, vocational rehabilitation services have now become core services of many treatment programs. Patients often work with trained vocational specialists who assist them with prevocational skill development (e.g., resume writing, job seeking skills), gaining work experience, educational assistance, and with finding and maintaining employment.
- Health and Medical Services - Normally, treatment programs give a complete physical examination or arrange for one to be provided upon initial admission. They also monitor other health conditions and diseases. Treatment programs are especially alert for certain diseases that are highly prevalent among chemical dependence patients (i.e., sexually transmitted diseases, hepatitis, tuberculosis and HIV/AIDS).
- Family Strengthening - Because chemical dependence strains and sometimes fractures important family relationships, treatment programs may offer - directly or through referral - services to strengthen family functioning and promote family reunification. These include a wide range of services depending on the individual's circumstances and could include family counseling, parenting education, childcare, and services to prevent or respond to domestic violence, trauma, or child abuse.
- Case Management - The multiple, complex needs of most patients extend beyond the specific chemical dependence services. For example, patients may need help with housing, transportation, court advocacy, childcare, or child welfare services. The treatment provider often works with the individual to arrange these critical services, make referrals, and assist in the exchange of vital information with other human service agencies. They help the person with the addiction overcome difficulties accessing or participating in such services.
It should be noted that historically alcohol and drug treatment programs have concentrated on returning each person to be a self-sufficient, productive member of his or her community. However, with the advent of welfare reform in 1995, many treatment organizations have made employment-related services even more important components of their treatment regimens. That is, the close alignment of welfare reform strategies and the renewed emphasis on work in the welfare system have reshaped some chemical dependence services, making employment readiness a more central feature of the chemical dependence system.
Where Does Treatment Occur?
Treatment occurs in a variety of settings. In fact, the treatment system represents a planned continuum of care in New York State. Many people with addictions start their initial treatment at one level (e.g., crisis services for detoxification) and move through the system until they can function as a productive and independent member of society. When an individual receives the maximum benefit from the treatment experience, discharge occurs. Each category of care provides a different intensity of treatment provision.
In New York State, the recent consolidation of alcohol treatment services and substance abuse treatment services into chemical dependence treatment services has resulted in four broad categories of care. (Private licensed practitioners also provide alcohol and substance abuse treatment, but they are not reflected in the four categories.) The four categories are summarized below.
Crisis Services (Detoxification and Withdrawal) - Chemical dependence crisis services manage the treatment of alcohol and/or substance withdrawal, as well as acute disorders associated with alcohol and/or substance use. These services are often provided early in a person's course of recovery and are relatively short in duration, typically three to five days, although some chemicals may require up to 30 days of managed withdrawal. Crisis services lead to a referral for continued care in a longer-term treatment setting. Crisis services include medically managed detoxification in a hospital, medically supervised withdrawal in either an inpatient/residential or outpatient setting, and medically monitored withdrawal in community-based settings. While services will vary with the patient and the setting, they can include: medical management of acute intoxication and withdrawal; assessment; stabilization of medical and psychiatric problems; counseling; pharmacological services; determination of appropriate long-term care; and referrals for other services.
Inpatient Rehabilitation - Chemical dependence inpatient rehabilitation services provide intensive management of chemical dependence symptoms and medical management and monitoring of physical or mental complications from chemical dependence to individuals who cannot be effectively served as outpatients and who are not in need of medical detoxification or acute care. These services can be provided in a hospital or freestanding facility. Lengths of stay are usually in the 20-40 day range.
Providers conduct intensive evaluation, treatment and rehabilitation services in a medically supervised 24 hour/day, 7 days/week setting. Chemical dependence inpatient services include the following basic clinical procedures: individual and group counseling and activities therapy; alcohol and substance abuse disease awareness and relapse prevention; assessment and referral services for patients, families and significant others; HIV education, risk assessment and supportive counseling and referral; vocational and/or educational assessment; and medical and psychiatric evaluation. In addition, patients are given education about, orientation to, and opportunity for participation in, available and relevant self-help groups.
Residential Services - Chemical dependence residential services assist individuals who are unable to maintain abstinence or participate in treatment without the structure of a 24-hour/day, 7 day/week residential setting, and who are not in need of acute hospital or psychiatric care or chemical dependence inpatient services. There are three levels of residential services, which vary by intensity of service provided: intensive residential treatment and rehabilitation, community residential services, and supportive living services. Length of stay ranges from an average of four months in a community residential service to up to two years in the other residential service categories.
All residential chemical dependence services provide the following procedures: counseling, peer group counseling, supportive services, educational services, structured activity, recreation, and orientation to community services. In addition, some provide the following additional services, either directly or by referral: vocational assessment and services; job skills and employment readiness training; and parenting, personal, social and community living skills training, including personal hygiene and leisure activities.
Outpatient Services - Outpatient services may be provided in a freestanding setting or may be co-located in a variety of other health and human service settings. Ideally, outpatient services are delivered in the community where the individual lives. This encourages access to the person's family and other community supports that will help the client maintain an alcohol and substance free life.
There are two types of chemical dependence outpatient services: general outpatient services and outpatient rehabilitation services. Rehabilitation services see clients more frequently (daily initially) and these programs have more staff per client than the more general outpatient programs because persons attending rehabilitation service programs have greater needs. The length of stay and the intensity of services as measured by frequency and duration of visits vary from one category of outpatient services to another. The frequency with which a patient participates in outpatient services also varies during the course of treatment depending on how he or she progresses toward recovery. In general, persons are engaged in outpatient treatment up to a year, with visits more frequent earlier in the treatment process and becoming less frequent as treatment progresses.
Each chemical dependence outpatient service provides the following procedures: group and individual counseling; education about alcohol and substance abuse disease awareness and relapse prevention; HIV and other communicable disease education, risk assessment, supportive counseling and referral; and family treatment. In addition, and as with all levels of service, patients are given orientation to, and opportunity for participation in, relevant and available self-help groups. Providers must make available - either directly or through written agreements - social and health care services, activity therapies, information and education about nutritional requirements, and vocational and educational evaluation. All services are provided according to an individualized evaluation and treatment plan.
Who Provides Treatment?
Depending on the treatment program and the individual circumstances, a wide variety of professionals can be involved in a person's treatment. Most commonly, people receive treatment which is overseen by a multi-disciplinary team of professionals under the employment of a treatment program as summarized in the previous section. Programs can be for-profit, not-for-profit, and, in New York State, the state, counties and some cities deliver publicly operated chemical dependence treatment services. New York State law requires that chemical dependence treatment organizations must be certified by the Office of Alcoholism and Substance Abuse Services to provide services in New York State. In addition, professionals with appropriate state licensure may operate out of a private practice to provide treatment services. Examples of these private practitioners include: Physicians, Psychologists, Certified Social Workers and Psychiatrists.
In the chemical dependence treatment program, the alcoholism and substance abuse counselor typically provides the core treatment service. To ensure the highest caliber services, the Office of Alcoholism and Substance Abuse Services credentials alcoholism and substance abuse counselors (CASAC's). The credential requires the CASAC to demonstrate a combination of relevant education and work experience, and to pass a formal examination. In addition to the CASAC, the following professionals commonly deliver treatment services to chemical dependence patients:
- Social Workers;
- Rehabilitation Counselors and other Vocational Specialists;
- Nurse Practitioners and Physician Assistants;
- Family Counselors; and
- Recreation Therapists.
Chemical dependence is a disease for which there are accessible effective treatments. With advances in research, treatment practice has improved, leading to restored hope and self-sufficiency among chemically dependent persons, and to stronger families that can provide the love and support essential for recovery. Improvement in treatment has also reduced the enormous economic toll this disease takes on the nation.
New York State has responded to the needs of its citizens for chemical dependence treatment services with a comprehensive system of care. Because treatment saves lives, restores health to the chemically dependent person and his or her family, and saves money, persons needing assistance should be aggressively referred to someone or someplace that can help them gain admittance into treatment. Treatment programs, knowledgeable health professionals, local Councils on Alcoholism and Drug Addictions, Employee Assistance Programs, and many self-help groups can help individuals find treatment. Collaborations between treatment agencies and criminal justice, mental health, welfare, and child welfare agencies also identify and refer persons to necessary treatment.
For people needing assistance, the OASAS toll-free information and referral line 1-877-8HOPENY (1-877-846-7369) will assist with referrals.
Additional information can be found on the OASAS Internet Web Site http://www.oasas.ny.gov/.
Principles of Effective Treatment
Adapted from "Principles of Drug Addiction Treatment"
National Institute on Drug Abuse (NIDA)
NIH Publication No. 00-4180
A few minor, modifications were made to the language contained in the original 13 principles set forth by NIDA. The NIDA publication was written specifically for - and was limited to - drug addiction treatment. This OASAS paper encompasses all alcohol and substance abuse treatment. Therefore, the most significant change to the 13 principles is to broaden them to be applicable for all chemical dependence treatment. In addition, the term "patient," has sometimes been changed to "individual" to reflect New York's view of the chemical dependence client as an active participant and consumer or customer of services.
- 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 society.
- Treatment needs to be readily available. Because individuals who are addicted 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 alcohol or substance use. To be effective, treatment must address the individual's alcohol and substance 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. An individual may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a person 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 persons, 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 individuals in treatment.
- Counseling (Individual and/or group) and other behavioral therapies and critical components of effective treatment for addiction. In therapy, individuals address issues of motivation, build skills to resist alcohol and substance use, replace alcohol and substance-using activities with constructive and rewarding non-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 addicted individuals, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetyl-methadol (LAAM) 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 individuals with co-occurring alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For persons with mental disorders, both behavioral treatments and medications can be critically important.
- Addicted 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, persons 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 use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help addicted persons achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective alcohol and 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 increase significantly both treatment entry and retention rates and the success of treatment interventions.
- Possible alcohol and/or drug use during treatment must be monitored continuously. Lapses to alcohol and/or drug use can occur during treatment. The objective monitoring of a person's drug and alcohol use during treatment, such as through urinalysis or other tests, can help the individual withstand urges to use. Such monitoring also can provide early evidence of alcohol or drug use so that the individual's treatment plan can be adjusted. Feedback to persons who test positive for alcohol or 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 persons modify or change behaviors that place themselves or other at risk of infection. Counseling can help individuals avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.
- Recovery from 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 abstinence.