Frequently Asked Questions
1. Why do drug-addicted persons keep using drugs?
Nearly all addicted individuals believe at the outset that they can stop using drugs on their own, and most try to stop without treatment. Although some people are successful, many attempts result in failure to achieve longterm abstinence. Research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences, including an inability to exert control over the impulse to use drugs despite adverse consequences—the defining characteristic of addiction.
Understanding that addiction has such a fundamental biological component may help explain the difficulty of achieving and maintaining abstinence without treatment. Psychological stress from work, family problems, psychiatric illness, pain associated with medical problems, social cues (such as meeting individuals from one's drug-using past), or environmental cues (such as encountering streets, objects, or even smells associated with drug abuse) can trigger intense cravings without the individual even being consciously aware of the triggering event. Any one of these factors can hinder attainment of sustained abstinence and make relapse more likely. Nevertheless, research indicates that active participation in treatment is an essential component for good outcomes and can benefit even the most severely addicted individuals.
2. What is drug addiction treatment?
Drug treatment is intended to help addicted individuals stop compulsive drug seeking and use. Treatment can occur in a variety of settings, in many different forms, and 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.
There are a variety of evidence-based approaches to treating addiction. Drug treatment can include behavioral therapy (such as individual or group counseling, cognitive therapy, or contingency management), medications, or their combination. The specific type of treatment or combination of treatments will vary depending on the patient's individual needs and, often, on the types of drugs they use. The severity of addiction and previous efforts to stop using drugs can also influence a treatment approach. Finally, people who are addicted to drugs often suffer from other health (including other mental health), 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. Specific needs may relate to age, race, culture, sexual orientation, gender, pregnancy, other drug use, comorbid conditions (e.g., depression, HIV), parenting, housing, and employment, as well as physical and sexual abuse history.
Treatment medications, such as methadone, buprenorphine, and naltrexone, are available for individuals addicted to opioids, while nicotine preparations (patches, gum, lozenges, and nasal spray) and the medications varenicline and bupropion are available for individuals addicted to tobacco. Disulfiram, acamprosate, naltrexone, and topiramate are medications used for treating alcohol dependence, which commonly co-occurs with other drug addictions. In fact, most people with severe addiction are polydrug users and require treatment for all substances abused. Even combined alcohol and tobacco use has proven amenable to concurrent treatment for both substances.
Psychoactive medications, such as antidepressants, antianxiety 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.
Behavioral therapies can help motivate people to participate in drug treatment; offer strategies for coping with drug cravings; teach ways to avoid drugs and prevent relapse; and help individuals deal with relapse if it occurs. Behavioral therapies can also help people improve communication, relationship, and parenting skills, as well as family dynamics.
Many treatment programs employ both individual and group therapies. Group therapy can provide social reinforcement and help enforce behavioral contingencies that promote abstinence and a non-drug-using lifestyle. Some of the more established behavioral treatments, such as contingency management and cognitive-behavioral therapy, are also being adapted for group settings to improve efficiency and cost-effectiveness. However, particularly in adolescents, there can also be a danger of iatrogenic, or inadvertent, effects of group treatment; thus, trained counselors should be aware and monitor for such effects.
Because they work on different aspects of addiction, combinations of behavioral therapies and medications (when available) generally appear to be more effective than either approach used alone.
3. How effective is drug addiction treatment?
In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. For example, 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, the appropriateness of treatment and related services used to address those problems, and the quality of interaction between the patient and his or her treatment providers.
Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction's powerful disruptive effects on the brain and behavior and to regain control of their lives. The chronic nature of the disease means that relapsing to drug abuse is not only possible but also likely, with relapse rates similar to those for other well-characterized chronic medical illnesses—such as diabetes, hypertension, and asthma (see figure,"Comparison of Relapse Rates Between Drug Addiction and Other Chronic Illnesses")—that also have both physiological and behavioral components.
Unfortunately, when relapse occurs many deem treatment a failure. This is not the case: successful treatment for addiction typically requires continual evaluation and modification as appropriate, similar to the approach taken for other chronic diseases. For example, when a patient is receiving active treatment for hypertension and symptoms decrease, treatment is deemed successful, even though symptoms may recur when treatment is discontinued. For the addicted patient, lapses to drug abuse do not indicate failure—rather, they signify that treatment needs to be reinstated or adjusted, or that alternate treatment is needed (see figure,"Why is Addiction Treatment Evaluated Defferent
4. Is drug addiction treatment worth its cost?
Substance abuse costs our Nation over one half-trillion dollars annually, and treatment can help reduce these costs. Drug addiction treatment has been shown to reduce associated health and social costs by far more than the cost of the treatment itself. Treatment is also much less expensive than its alternatives, such as incarcerating addicted persons. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $24,000 per person.
According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and to society also stem from fewer interpersonal conflicts; greater workplace productivity; and fewer drug-related accidents, including overdoses and deaths.
5. How long does drug addiction treatment usually last?
Individuals progress through drug addiction treatment at various rates, so there is no pre-determined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes. For methadone maintenance, 12 months is considered the minimum, and some opioid-addicted individuals continue to benefit from methadone maintenance for many years.
Treatment dropout is one of the major problems encountered by treatment programs; therefore, motivational techniques that can keep patients engaged will also improve outcomes. By viewing addiction as a chronic disease and offering continuing care and monitoring, programs can succeed, but this will often require multiple episodes of treatment and readily re-admitting patients that have relapsed.
6. What helps people stay in treatment?
Because successful outcomes often depend on a person's staying in treatment long enough to reap its full benefits, strategies for keeping people in treatment are critical. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Individual factors related to engagement and retention typically include motivation to change drug-using behavior; degree of support from family and friends; and, frequently, pressure from the criminal justice system, child protection services, employers, or the family. Within a treatment program, successful clinicians can establish a positive, therapeutic relationship with their patients. The clinician should ensure that a treatment plan is developed cooperatively with the person seeking treatment, that the plan is followed, and that treatment expectations are clearly understood. Medical, psychiatric, and social services should also be available.
Because some problems (such as serious medical or mental illness or criminal involvement) increase the likelihood of patients dropping out of treatment, intensive interventions may be required to retain them. After a course of intensive treatment, the provider should ensure a transition to less intensive continuing care to support and monitor individuals in their ongoing recovery.
7. How do we get more substance-abusing people into treatment?
It has been known for many years that the "treatment gap" is massive—that is, among those who need treatment for a substance use disorder, few receive it. In 2007, 23.2 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem, but only 3.9 million received treatment at a specialty substance abuse facility.
Reducing this gap requires a multipronged approach. Strategies include increasing access to effective treatment, achieving insurance parity (now in its earliest phase of implementation), reducing stigma, and raising awareness among both patients and health care professionals of the value of addiction treatment. To assist physicians in identifying treatment need in their patients and making appropriate referrals, NIDA is encouraging widespread use of screening, brief intervention, and referral to treatment (SBIRT) tools for use in primary care settings. SBIRT—which has proven effective against tobacco and alcohol use—has the potential not only to catch people before serious drug problems develop but also to connect them with appropriate treatment providers.
8. How can families and friends make a difference in the life of someone needing treatment?
Family and friends can play critical roles in motivating individuals with drug problems to enter and stay in treatment. Family therapy can also be important, especially for adolescents. Involvement of a family member or significant other in an individual's treatment program can strengthen and extend treatment benefits.
9. Where can family members go for information on treatment options?
Trying to locate appropriate treatment for a loved one, especially finding a program tailored to an individual's particular needs, can be a difficult process. However, there are some resources currently available to help with this process, including—
The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a Web site (www.findtreatment.samhsa.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 (www.nami.org) and Mental Health
- The
- For information about participating in a clinical trial testing promising substance abuse interventions, contact NIDA's National Drug Abuse Treatment Clinical Trials Network at www.drugabuse.gov/CTN/Index.htm, or visit NIH's Web site at www.clinicaltrials.gov.
10. How can the workplace play a role in substance abuse treatment?
Many workplaces sponsor Employee Assistance Programs (EAPs) that offer short-term counseling and/or assistance in linking employees with drug or alcohol problems to local treatment resources, including peer support/recovery groups. In addition, therapeutic work environments that provide employment for drug-abusing individuals who can demonstrate abstinence have been shown not only to promote a continued drug-free lifestyle but also to improve job skills, punctuality, and other behaviors necessary for active employment throughout life. Urine testing facilities, trained personnel, and workplace monitors are needed to implement this type of treatment.
11. What role can the criminal justice system play in addressing drug addiction?
Research has demonstrated that treatment for drugaddicted offenders during and after incarceration can have a significant effect on future drug use, criminal behavior, and social functioning. The case for integrating drug addiction treatment approaches with the criminal justice system is compelling. Combining prison- and community-based treatment for addicted offenders reduces the risk of both recidivism to drug-related criminal behavior and relapse to drug use, which, in turn, nets huge savings in societal costs. One study found that prisoners who participated in a therapeutic treatment program in the
The majority of offenders involved with the criminal justice system are not in prison but are under community supervision. For those with known drug problems, drug addiction treatment may be recommended or mandated as a condition of probation. Research has demonstrated that individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily.
The criminal justice system refers drug offenders into treatment through a variety of mechanisms, such as diverting nonviolent offenders to treatment; stipulating treatment as a condition of incarceration, probation, or pretrial release; and convening specialized courts, or drug courts, that handle drug offense cases. These courts mandate and arrange for treatment as an alternative to incarceration, actively monitor progress in treatment, and arrange for other services for drug-involved offenders.
The most effective models integrate criminal justice and drug treatment systems and services. Treatment and criminal justice personnel work together on treatment planning—including implementation of screening, placement, testing, monitoring, and supervision—as well as on the systematic use of sanctions and rewards. Treatment for incarcerated drug abusers should include continuing care, monitoring, and supervision after incarceration and during parole. (For more information, please see NIDA's Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide [revised 2007].)
12. What are the unique needs of women with substance use disorders?
Gender-related drug abuse treatment should attend not only to biological differences but also to social and environmental factors, all of which can influence the motivations for drug use, the reasons for seeking treatment, the types of environments where treatment is obtained, the treatments that are most effective, and the consequences of not receiving treatment. Many life circumstances predominate in women as a group, which may require a specialized treatment approach. For example, research has shown that physical and sexual trauma followed by post-traumatic stress disorder (PTSD) is more common in drug-abusing women than in men seeking treatment. Other factors unique to women that can influence the treatment process include issues around pregnancy and child care, financial independence, and how they come into treatment (as women are more likely to seek the assistance of a general or mental health practitioner).
13. What are the unique needs of adolescents with substance use disorders?
Adolescent drug abusers have unique needs stemming from their immature neurocognitive and psychosocial stage of development. Research has demonstrated that the brain undergoes a prolonged process of development and refinement, from birth to early adulthood, during which a developmental shift occurs where actions go from more impulsive to more reasoned and reflective. In fact, the brain areas most closely associated with aspects of behavior such as decisionmaking, judgment, planning, and self-control undergo a period of rapid development during adolescence.
Adolescent drug abuse is also often associated with other co-occurring mental health problems. These include attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct problems, as well as depressive and anxiety disorders. This developmental period has also been associated with physical and/or sexual abuse and academic difficulties.
Adolescents are also especially sensitive to social cues, with peer groups and families being highly influential during this time. Therefore, treatments that facilitate positive parental involvement, integrate other systems in which the adolescent participates (such as school and athletics), and recognize the importance of prosocial peer relationships are among the most effective. Access to comprehensive assessment, treatment, case management, and family-support services that are developmentally, culturally, and gender-appropriate is also integral when addressing adolescent addiction.
Medications for substance abuse among adolescents may also be helpful. Currently, the only Food and Drug Administration (FDA)-approved addiction medication for adolescents is the transdermal nicotine patch. Research is under way to determine the safety and efficacy of medications for nicotine-, alcohol-, and opioid-dependent adolescents and for adolescents with co-occurring disorders.
14. Are there specific drug addiction treatments for older adults?
With the aging of the baby boomer generation, the composition of the general population will expand dramatically with respect to the number of older adults. Such a change, coupled with a greater history of lifetime drug use (than previous older generations), different cultural norms and general attitudes about drug use, and increases in the availability of psychotherapeutic medications, may lead to growth in the number of older adults with substance use problems. Although no drug treatment programs are yet designed exclusively for older adults, research to date indicates that current addiction treatment programs can be as effective for older adults as they are for younger adults. However, substance abuse problems in older adults often go unrecognized, and therefore untreated.
15. Are there treatments for people addicted to prescription drugs?
The nonmedical use of prescription drugs increased dramatically in the 1990s and remains at high levels. In 2007, approximately 7 million people aged 12 or older reported nonmedical use of a prescription drug. The most commonly abused medications are painkillers (i.e., opioids: 5.2 million people), stimulants (e.g., methylphenidate and amphetamine: 1.2 million), and central nervous system (CNS) depressants (e.g., benzodiazepines: 2.1 million). Like many illicit substances, these drugs alter the brain's activity and can lead to many adverse consequences, including addiction. For example, opioid pain relievers, such as Vicodin or OxyContin, can present similar health risks as do illicit opioids (e.g., heroin) depending on dose, route of administration, combination with other drugs, and other factors. As a result, the increases in nonmedical use have been accompanied by increased emergency room visits, accidental poisonings, and treatment admissions for addiction. Treatments for prescription drugs tend to be similar to those for illicit drugs that affect the same brain systems. Thus, buprenorphine is used to treat addiction to opioid pain medications, and behavioral therapies are most likely to be effective for stimulant or CNS depressant addiction—for which we do not yet have medications.
16. Is there a difference between physical dependence and addiction?
Yes. According to the DSM, the clinical criteria for "drug dependence" (or what we refer to as addiction) include compulsive drug use despite harmful consequences; inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including even appropriate, medically instructed use. Thus, physical dependence in and of itself does not constitute addiction, but often accompanies addiction. This distinction can be difficult to discern, particularly with prescribed pain medications, where the need for increasing dosages can represent tolerance or a worsening underlying problem, as opposed to the beginning of abuse or addiction.
17. Can a person become addicted to psychotherapeutics that are prescribed by a doctor?
While this scenario occurs infrequently, it is possible. Because some psychotherapeutics have a risk of addiction associated with them (e.g., stimulants to treat ADHD, benzodiazepines to treat anxiety or sleep disorders, and opioids to treat pain), it is important for patients to follow their physician's instructions faithfully and for physicians to monitor their patients carefully. To minimize these risks, a physician (or other prescribing health provider) should be aware of a patient's prior or current substance abuse problems, as well as their family history with regard to addiction. This will help determine risk and need for monitoring.
18. How do other mental disorders coexisting with drug addiction affect drug addiction treatment?
Drug addiction is a disease of the brain that frequently occurs with other mental disorders. In fact, as many as 6 in 10 people with an illicit substance use disorder also suffer from another mental illness; and rates are similar for users of licit drugs—i.e., tobacco and alcohol. For these individuals, one condition becomes more difficult to treat successfully as an additional condition is intertwined. Thus, patients entering treatment either for a substance use disorder or for another mental disorder should be assessed for the co-occurrence of the other condition. Research indicates that treating both (or multiple) illnesses simultaneously in an integrated fashion is generally the best treatment approach for these patients.
19. Is the use of medications like methadone and buprenorphine simply replacing one drug addiction with another?
No—as used in maintenance treatment, buprenorphine and methadone are not heroin/opioid substitutes. They 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 pharmacological 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 euphoria, that wears off quickly and ends in a "crash." The individual then experiences an intense craving to use again so as 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.
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 the 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.
20. Where do 12-step or self-help programs fit into drug addiction treatment?
Self-help groups can complement and extend the effects of professional treatment. The most prominent self-help groups are those affiliated with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. Most drug addiction treatment programs encourage patients to participate in self-help group therapy during and after formal treatment. These groups can be particularly helpful during recovery, offering an added layer of community-level social support to help people achieve and maintain abstinence and other healthy lifestyle behaviors over the course of a lifetime.
21. Can exercise play a role in the treatment process?
Yes—exercise is increasingly becoming a component of many treatment programs and has shown efficacy, in combination with cognitive-behavioral therapy, for promoting smoking cessation. Exercise may exert beneficial effects by addressing psychosocial and physiological needs that nicotine replacement alone does not; attenuating negative affect; reducing stress; and helping prevent weight gain following cessation. Research is currently under way to determine if and how exercise programs can play a similar role in the treatment of other forms of drug abuse.
22. How does drug addiction treatment help reduce the spread of HIV/ AIDS, hepatitis C (HCV), and other infectious diseases?
Drug-abusing individuals, including injecting and non-injecting drug users, are at increased risk of HIV, HCV, and other infectious diseases. These diseases are transmitted by sharing contaminated drug injection equipment and by engaging in risky sexual behavior sometimes associated with drug use. Effective drug abuse treatment is HIV/HCV prevention because it reduces associated risk behaviors as well as drug abuse. Counseling that targets a range of HIV/HCV risk behaviors provides an added level of disease prevention.
Drug injectors who do not enter treatment are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment because the latter reduce activities that can spread disease, such as sharing injection equipment and engaging in unprotected sexual activity. Participation in treatment also presents opportunities for screening, counseling, and referral to additional services, including early HIV treatment and access to HAART. In fact, HIV counseling and testing are key aspects of superior drug abuse treatment programs and should be offered to all individuals entering treatment. Greater availability of inexpensive and unobtrusive rapid HIV tests should increase access to these important aspects of HIV prevention and treatment.
No comments:
Post a Comment