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NationalInstituteonDrugAbuse(NIDA)
PrinciplesofDrugAddictionTreatment:AResearch-BasedGuide(ThirdEdition)
LastUpdatedJanuary2018
https://www.drugabuse.gov
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TableofContents
PrinciplesofDrugAddictionTreatment:AResearch-BasedGuide(Third
Edition)
Preface
PrinciplesofEffectiveTreatment
FrequentlyAskedQuestions
DrugAddictionTreatmentintheUnitedStates
Evidence-BasedApproachestoDrugAddictionTreatment
Resources
Acknowledgments
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Preface
Drugaddictionisacomplexillness.
Itischaracterizedbyintenseand,attimes,uncontrollabledrug
craving,alongwithcompulsivedrugseekingandusethatpersisteven
inthefaceofdevastatingconsequences.ThisupdateoftheNational
InstituteonDrugAbuse’sPrinciplesofDrugAddictionTreatmentis
intendedtoaddressaddictiontoawidevarietyofdrugs,including
nicotine,alcohol,andillicitandprescriptiondrugs.Itisdesignedto
serveasaresourceforhealthcareproviders,familymembers,and
otherstakeholderstryingtoaddressthemyriadproblemsfacedby
patientsinneedoftreatmentfordrugabuseoraddiction.
Addictionaffectsmultiplebraincircuits,includingthoseinvolvedin
rewardandmotivation,learningandmemory,andinhibitorycontrol
overbehavior.Thatiswhyaddictionisabraindisease.Some
individualsaremorevulnerablethanotherstobecomingaddicted,
dependingontheinterplaybetweengeneticmakeup,ageofexposure
todrugs,andotherenvironmentalinfluences.Whileapersoninitially
choosestotakedrugs,overtimetheeffectsofprolongedexposureon
brainfunctioningcompromisethatabilitytochoose,andseekingand
consumingthedrugbecomecompulsive,ofteneludingaperson’sself-
controlorwillpower.
Butaddictionismorethanjustcompulsivedrugtaking—itcanalso
producefar-reachinghealthandsocialconsequences.Forexample,
drugabuseandaddictionincreaseaperson’sriskforavarietyofother
mentalandphysicalillnessesrelatedtoadrug-abusinglifestyleorthe
toxiceffectsofthedrugsthemselves.Additionally,thedysfunctional
behaviorsthatresultfromdrugabusecaninterferewithaperson’s
normalfunctioninginthefamily,theworkplace,andthebroader
community.
Becausedrugabuseandaddictionhavesomanydimensionsand
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disruptsomanyaspectsofanindividual’slife,treatmentisnotsimple.
Effectivetreatmentprogramstypicallyincorporatemanycomponents,
eachdirectedtoaparticularaspectoftheillnessanditsconsequences.
Addictiontreatmentmusthelptheindividualstopusingdrugs,
maintainadrug-freelifestyle,andachieveproductivefunctioningin
thefamily,atwork,andinsociety.Becauseaddictionisadisease,most
peoplecannotsimplystopusingdrugsforafewdaysandbecured.
Patientstypicallyrequirelong-termorrepeatedepisodesofcareto
achievetheultimategoalofsustainedabstinenceandrecoveryoftheir
lives.Indeed,scientificresearchandclinicalpracticedemonstratethe
valueofcontinuingcareintreatingaddiction,withavarietyof
approacheshavingbeentestedandintegratedinresidentialand
communitysettings.
Aswelooktowardthefuture,wewillharnessnewresearchresultson
theinfluenceofgeneticsandenvironmentongenefunctionand
expression(i.e.,epigenetics),whichareheraldingthedevelopmentof
personalizedtreatmentinterventions.Thesefindingswillbeintegrated
withcurrentevidencesupportingthemosteffectivedrugabuseand
addictiontreatmentsandtheirimplementation,whicharereflectedin
thisguide.
NoraD.Volkow,M.D.
Director
NationalInstituteonDrugAbuse
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PrinciplesofEffective
Treatment
1. Addictionisacomplexbuttreatablediseasethataffects
brainfunctionandbehavior.Drugsofabusealterthebrain’s
structureandfunction,resultinginchangesthatpersistlongafter
drugusehasceased.Thismayexplainwhydrugabusersareat
riskforrelapseevenafterlongperiodsofabstinenceanddespite
thepotentiallydevastatingconsequences.
2. Nosingletreatmentisappropriateforeveryone.Treatment
variesdependingonthetypeofdrugandthecharacteristicsof
thepatients.Matchingtreatmentsettings,interventions,and
servicestoanindividual’sparticularproblemsandneedsiscritical
tohisorherultimatesuccessinreturningtoproductive
functioninginthefamily,workplace,andsociety.
3. Treatmentneedstobereadilyavailable.Becausedrug-
addictedindividualsmaybeuncertainaboutenteringtreatment,
takingadvantageofavailableservicesthemomentpeopleare
readyfortreatmentiscritical.Potentialpatientscanbelostif
treatmentisnotimmediatelyavailableorreadilyaccessible.As
withotherchronicdiseases,theearliertreatmentisofferedinthe
diseaseprocess,thegreaterthelikelihoodofpositiveoutcomes.
4. Effectivetreatmentattendstomultipleneedsofthe
individual,notjusthisorherdrugabuse.Tobeeffective,
treatmentmustaddresstheindividual’sdrugabuseandany
associatedmedical,psychological,social,vocational,andlegal
problems.Itisalsoimportantthattreatmentbeappropriatetothe
individual’sage,gender,ethnicity,andculture.
5. Remainingintreatmentforanadequateperiodoftimeis
critical.Theappropriatedurationforanindividualdependson
thetypeanddegreeofthepatient’sproblemsandneeds.
Researchindicatesthatmostaddictedindividualsneedatleast3
monthsintreatmenttosignificantlyreduceorstoptheirdruguse
andthatthebestoutcomesoccurwithlongerdurationsof
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treatment.Recoveryfromdrugaddictionisalong-termprocess
andfrequentlyrequiresmultipleepisodesoftreatment.Aswith
otherchronicillnesses,relapsestodrugabusecanoccurand
shouldsignalaneedfortreatmenttobereinstatedoradjusted.
Becauseindividualsoftenleavetreatmentprematurely,programs
shouldincludestrategiestoengageandkeeppatientsin
treatment.
6. Behavioraltherapies—includingindividual,family,orgroup
counseling—arethemostcommonlyusedformsofdrug
abusetreatment.Behavioraltherapiesvaryintheirfocusand
mayinvolveaddressingapatient’smotivationtochange,
providingincentivesforabstinence,buildingskillstoresistdrug
use,replacingdrug-usingactivitieswithconstructiveand
rewardingactivities,improvingproblem-solvingskills,and
facilitatingbetterinterpersonalrelationships.Also,participationin
grouptherapyandotherpeersupportprogramsduringand
followingtreatmentcanhelpmaintainabstinence.
7. Medicationsareanimportantelementoftreatmentfor
manypatients,especiallywhencombinedwithcounseling
andotherbehavioraltherapies.Forexample,methadone,
buprenorphine,andnaltrexone(includinganewlong-acting
formulation)areeffectiveinhelpingindividualsaddictedtoheroin
orotheropioidsstabilizetheirlivesandreducetheirillicitdrug
use.Acamprosate,disulfiram,andnaltrexonearemedications
approvedfortreatingalcoholdependence.Forpersonsaddictedto
nicotine,anicotinereplacementproduct(availableaspatches,
gum,lozenges,ornasalspray)oranoralmedication(suchas
bupropionorvarenicline)canbeaneffectivecomponentof
treatmentwhenpartofacomprehensivebehavioraltreatment
program.
8. Anindividual'streatmentandservicesplanmustbe
assessedcontinuallyandmodifiedasnecessarytoensure
thatitmeetshisorherchangingneeds.Apatientmay
requirevaryingcombinationsofservicesandtreatment
componentsduringthecourseoftreatmentandrecovery.In
additiontocounselingorpsychotherapy,apatientmayrequire
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medication,medicalservices,familytherapy,parenting
instruction,vocationalrehabilitation,and/orsocialandlegal
services.Formanypatients,acontinuingcareapproachprovides
thebestresults,withthetreatmentintensityvaryingaccordingto
aperson’schangingneeds.
9. Manydrug-addictedindividualsalsohaveothermental
disorders.Becausedrugabuseandaddiction—bothofwhichare
mentaldisorders—oftenco-occurwithothermentalillnesses,
patientspresentingwithoneconditionshouldbeassessedforthe
other(s).Andwhentheseproblemsco-occur,treatmentshould
addressboth(orall),includingtheuseofmedicationsas
appropriate.
10. Medicallyassisteddetoxificationisonlythefirststageof
addictiontreatmentandbyitselfdoeslittletochange
long-termdrugabuse.Althoughmedicallyassisted
detoxificationcansafelymanagetheacutephysicalsymptomsof
withdrawalandcan,forsome,pavethewayforeffectivelong-
termaddictiontreatment,detoxificationaloneisrarelysufficient
tohelpaddictedindividualsachievelong-termabstinence.Thus,
patientsshouldbeencouragedtocontinuedrugtreatment
followingdetoxification.Motivationalenhancementandincentive
strategies,begunatinitialpatientintake,canimprovetreatment
engagement.
11. Treatmentdoesnotneedtobevoluntarytobeeffective.
Sanctionsorenticementsfromfamily,employmentsettings,
and/orthecriminaljusticesystemcansignificantlyincrease
treatmententry,retentionrates,andtheultimatesuccessofdrug
treatmentinterventions.
12. Druguseduringtreatmentmustbemonitored
continuously,aslapsesduringtreatmentdooccur.Knowing
theirdruguseisbeingmonitoredcanbeapowerfulincentivefor
patientsandcanhelpthemwithstandurgestousedrugs.
Monitoringalsoprovidesanearlyindicationofareturntodrug
use,signalingapossibleneedtoadjustanindividual’streatment
plantobettermeethisorherneeds.
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13. Treatmentprogramsshouldtestpatientsforthepresence
ofHIV/AIDS,hepatitisBandC,tuberculosis,andother
infectiousdiseasesaswellasprovidetargetedrisk-
reductioncounseling,linkingpatientstotreatmentif
necessary.Typically,drugabusetreatmentaddressessomeof
thedrug-relatedbehaviorsthatputpeopleatriskofinfectious
diseases.Targetedcounselingfocusedonreducinginfectious
diseaseriskcanhelppatientsfurtherreduceoravoidsubstance-
relatedandotherhigh-riskbehaviors.Counselingcanalsohelp
thosewhoarealreadyinfectedtomanagetheirillness.Moreover,
engaginginsubstanceabusetreatmentcanfacilitateadherence
toothermedicaltreatments.Substanceabusetreatmentfacilities
shouldprovideonsite,rapidHIVtestingratherthanreferralsto
offsitetesting—researchshowsthatdoingsoincreasesthe
likelihoodthatpatientswillbetestedandreceivetheirtestresults.
Treatmentprovidersshouldalsoinformpatientsthathighlyactive
antiretroviraltherapy(HAART)hasproveneffectiveincombating
HIV,includingamongdrug-abusingpopulations,andhelplink
themtoHIVtreatmentiftheytestpositive.
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FrequentlyAskedQuestions
Treatmentvariesdependingonthetypeofdrugandthe
characteristicsofthepatient.Thebestprogramsprovidea
combinationoftherapiesandotherservices.
Whydodrug-addictedpersons
keepusingdrugs?
Nearlyalladdictedindividualsbelieveattheoutsetthattheycanstop
usingdrugsontheirown,andmosttrytostopwithouttreatment.
Althoughsomepeoplearesuccessful,manyattemptsresultinfailure
toachievelong-termabstinence.Researchhasshownthatlong-term
drugabuseresultsinchangesinthebrainthatpersistlongaftera
personstopsusingdrugs.Thesedrug-inducedchangesinbrain
functioncanhavemanybehavioralconsequences,includingan
inabilitytoexertcontrolovertheimpulsetousedrugsdespiteadverse
consequences—thedefiningcharacteristicofaddiction.
Long-termdruguseresultsinsignificantchangesinbrainfunction
thatcanpersistlongaftertheindividualstopsusingdrugs.
Understandingthataddictionhassuchafundamentalbiological
componentmayhelpexplainthedifficultyofachievingand
maintainingabstinencewithouttreatment.Psychologicalstressfrom
work,familyproblems,psychiatricillness,painassociatedwithmedical
problems,socialcues(suchasmeetingindividualsfromone’sdrug-
usingpast),orenvironmentalcues(suchasencounteringstreets,
objects,orevensmellsassociatedwithdrugabuse)cantriggerintense
cravingswithouttheindividualevenbeingconsciouslyawareofthe
triggeringevent.Anyoneofthesefactorscanhinderattainmentof
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sustainedabstinenceandmakerelapsemorelikely.Nevertheless,
researchindicatesthatactiveparticipationintreatmentisanessential
componentforgoodoutcomesandcanbenefiteventhemostseverely
addictedindividuals.
Whatisdrugaddictiontreatment?
Drugtreatmentisintendedtohelpaddictedindividualsstop
compulsivedrugseekinganduse.Treatmentcanoccurinavarietyof
settings,takemanydifferentforms,andlastfordifferentlengthsof
time.Becausedrugaddictionistypicallyachronicdisorder
characterizedbyoccasionalrelapses,ashort-term,one-timetreatment
isusuallynotsufficient.Formany,treatmentisalong-termprocess
thatinvolvesmultipleinterventionsandregularmonitoring.
Thereareavarietyofevidence-basedapproachestotreatingaddiction.
Drugtreatmentcanincludebehavioraltherapy(suchascognitive-
behavioraltherapyorcontingencymanagement),medications,ortheir
combination.Thespecifictypeoftreatmentorcombinationof
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treatmentswillvarydependingonthepatient’sindividualneedsand,
often,onthetypesofdrugstheyuse.
Drugaddictiontreatmentcanincludemedications,behavioral
therapies,ortheircombination.
Treatmentmedications,suchasmethadone,buprenorphine,and
naltrexone(includinganewlong-actingformulation),areavailablefor
individualsaddictedtoopioids,whilenicotinepreparations(patches,
gum,lozenges,andnasalspray)andthemedicationsvareniclineand
bupropionareavailableforindividualsaddictedtotobacco.Disulfiram,
acamprosate,andnaltrexonearemedicationsavailablefortreating
alcoholdependence, whichcommonlyco-occurswithotherdrug
addictions,includingaddictiontoprescriptionmedications.
Treatmentsforprescriptiondrugabusetendtobesimilartothosefor
illicitdrugsthataffectthesamebrainsystems.Forexample,
buprenorphine,usedtotreatheroinaddiction,canalsobeusedtotreat
addictiontoopioidpainmedications.Addictiontoprescription
stimulants,whichaffectthesamebrainsystemsasillicitstimulantslike
cocaine,canbetreatedwithbehavioraltherapies,astherearenotyet
medicationsfortreatingaddictiontothesetypesofdrugs.
Behavioraltherapiescanhelpmotivatepeopletoparticipateindrug
treatment,offerstrategiesforcopingwithdrugcravings,teachwaysto
avoiddrugsandpreventrelapse,andhelpindividualsdealwithrelapse
ifitoccurs.Behavioraltherapiescanalsohelppeopleimprove
communication,relationship,andparentingskills,aswellasfamily
dynamics.
Manytreatmentprogramsemploybothindividualandgrouptherapies.
Grouptherapycanprovidesocialreinforcementandhelpenforce
behavioralcontingenciesthatpromoteabstinenceandanon-drug-
usinglifestyle.Someofthemoreestablishedbehavioraltreatments,
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suchascontingencymanagementandcognitive-behavioraltherapy,
arealsobeingadaptedforgroupsettingstoimproveefficiencyand
cost-effectiveness.However,particularlyinadolescents,therecanalso
beadangerofunintendedharmful(oriatrogenic)effectsofgroup
treatment—sometimesgroupmembers(especiallygroupsofhighly
delinquentyouth)canreinforcedruguseandtherebyderailthe
purposeofthetherapy.Thus,trainedcounselorsshouldbeawareof
andmonitorforsucheffects.
Becausetheyworkondifferentaspectsofaddiction,combinationsof
behavioraltherapiesandmedications(whenavailable)generally
appeartobemoreeffectivethaneitherapproachusedalone.
Finally,peoplewhoareaddictedtodrugsoftensufferfromotherhealth
(e.g.,depression,HIV),occupational,legal,familial,andsocial
problemsthatshouldbeaddressedconcurrently.Thebestprograms
provideacombinationoftherapiesandotherservicestomeetan
individualpatient’sneeds.Psychoactivemedications,suchas
antidepressants,anti-anxietyagents,moodstabilizers,and
antipsychoticmedications,maybecriticalfortreatmentsuccesswhen
patientshaveco-occurringmentaldisorderssuchasdepression,
anxietydisorders(includingpost-traumaticstressdisorder),bipolar
disorder,orschizophrenia.Inaddition,mostpeoplewithsevere
addictionabusemultipledrugsandrequiretreatmentforall
substancesabused.
Treatmentfordrugabuseandaddictionisdeliveredinmany
differentsettingsusingavarietyofbehavioraland
pharmacologicalapproaches.
Anotherdrug,topiramate,hasalsoshownpromiseinstudiesandis
sometimesprescribed(off-label)forthispurposealthoughithasnot
receivedFDAapprovalasatreatmentforalcoholdependence.
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Howeffectiveisdrugaddiction
treatment?
Inadditiontostoppingdrugabuse,thegoaloftreatmentistoreturn
peopletoproductivefunctioninginthefamily,workplace,and
community.Accordingtoresearchthattracksindividualsintreatment
overextendedperiods,mostpeoplewhogetintoandremainin
treatmentstopusingdrugs,decreasetheircriminalactivity,and
improvetheiroccupational,social,andpsychologicalfunctioning.For
example,methadonetreatmenthasbeenshowntoincrease
participationinbehavioraltherapyanddecreasebothdruguseand
criminalbehavior.However,individualtreatmentoutcomesdependon
theextentandnatureofthepatient’sproblems,theappropriatenessof
treatmentandrelatedservicesusedtoaddressthoseproblems,and
thequalityofinteractionbetweenthepatientandhisorhertreatment
providers.
Relapseratesforaddictionresemblethoseofotherchronic
diseasessuchasdiabetes,hypertension,andasthma.
Likeotherchronicdiseases,addictioncanbemanagedsuccessfully.
Treatmentenablespeopletocounteractaddiction’spowerfuldisruptive
effectsonthebrainandbehaviorandtoregaincontroloftheirlives.
Thechronicnatureofthediseasemeansthatrelapsingtodrugabuse
isnotonlypossiblebutalsolikely,withsymptomrecurrencerates
similartothoseforotherwell-characterizedchronicmedicalillnesses—
suchasdiabetes,hypertension,andasthma(seefigure,"Comparison
ofRelapseRatesBetweenDrugAddictionandOtherChronicIllnesses”)
—thatalsohavebothphysiologicalandbehavioralcomponents.
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Unfortunately,whenrelapseoccursmanydeemtreatmentafailure.
Thisisnotthecase:Successfultreatmentforaddictiontypically
requirescontinualevaluationandmodificationasappropriate,similar
totheapproachtakenforotherchronicdiseases.Forexample,whena
patientisreceivingactivetreatmentforhypertensionandsymptoms
decrease,treatmentisdeemedsuccessful,eventhoughsymptoms
mayrecurwhentreatmentisdiscontinued.Fortheaddictedindividual,
lapsestodrugabusedonotindicatefailure—rather,theysignifythat
treatmentneedstobereinstatedoradjusted,orthatalternate
treatmentisneeded(seefigure,"WhyisAddictionTreatmentEvaluated
Differently?").
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Isdrugaddictiontreatmentworth
itscost?
SubstanceabusecostsourNationover$600billionannuallyand
treatmentcanhelpreducethesecosts.Drugaddictiontreatmenthas
beenshowntoreduceassociatedhealthandsocialcostsbyfarmore
thanthecostofthetreatmentitself.Treatmentisalsomuchless
expensivethanitsalternatives,suchasincarceratingaddictedpersons.
Forexample,theaveragecostfor1fullyearofmethadone
maintenancetreatmentisapproximately$4,700perpatient,whereas1
fullyearofimprisonmentcostsapproximately$24,000perperson.
Drugaddictiontreatmentreducesdruguseanditsassociated
healthandsocialcosts.
Accordingtoseveralconservativeestimates,everydollarinvestedin
addictiontreatmentprogramsyieldsareturnofbetween$4and$7in
reduceddrug-relatedcrime,criminaljusticecosts,andtheft.When
savingsrelatedtohealthcareareincluded,totalsavingscanexceed
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costsbyaratioof12to1.Majorsavingstotheindividualandto
societyalsostemfromfewerinterpersonalconflicts;greaterworkplace
productivity;andfewerdrug-relatedaccidents,includingoverdoses
anddeaths.
Howlongdoesdrugaddiction
treatmentusuallylast?
Individualsprogressthroughdrugaddictiontreatmentatvariousrates,
sothereisnopredeterminedlengthoftreatment.However,research
hasshownunequivocallythatgoodoutcomesarecontingenton
adequatetreatmentlength.Generally,forresidentialoroutpatient
treatment,participationforlessthan90daysisoflimited
effectiveness,andtreatmentlastingsignificantlylongeris
recommendedformaintainingpositiveoutcomes.Formethadone
maintenance,12monthsisconsideredtheminimum,andsomeopioid-
addictedindividualscontinuetobenefitfrommethadonemaintenance
formanyyears.
Goodoutcomesarecontingentonadequatetreatmentlength.
Treatmentdropoutisoneofthemajorproblemsencounteredby
treatmentprograms;therefore,motivationaltechniquesthatcankeep
patientsengagedwillalsoimproveoutcomes.Byviewingaddictionas
achronicdiseaseandofferingcontinuingcareandmonitoring,
programscansucceed,butthiswilloftenrequiremultipleepisodesof
treatmentandreadilyreadmittingpatientsthathaverelapsed.
Whathelpspeoplestayin
treatment?
Becausesuccessfuloutcomesoftendependonaperson’sstayingin
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treatmentlongenoughtoreapitsfullbenefits,strategiesforkeeping
peopleintreatmentarecritical.Whetherapatientstaysintreatment
dependsonfactorsassociatedwithboththeindividualandthe
program.Individualfactorsrelatedtoengagementandretention
typicallyincludemotivationtochangedrug-usingbehavior;degreeof
supportfromfamilyandfriends;and,frequently,pressurefromthe
criminaljusticesystem,childprotectionservices,employers,orfamily.
Withinatreatmentprogram,successfulclinicianscanestablisha
positive,therapeuticrelationshipwiththeirpatients.Theclinician
shouldensurethatatreatmentplanisdevelopedcooperativelywith
thepersonseekingtreatment,thattheplanisfollowed,andthat
treatmentexpectationsareclearlyunderstood.Medical,psychiatric,
andsocialservicesshouldalsobeavailable.
Whetherapatientstaysintreatmentdependsonfactors
associatedwithboththeindividualandtheprogram.
Becausesomeproblems(suchasseriousmedicalormentalillnessor
criminalinvolvement)increasethelikelihoodofpatientsdroppingout
oftreatment,intensiveinterventionsmayberequiredtoretainthem.
Afteracourseofintensivetreatment,theprovidershouldensurea
transitiontolessintensivecontinuingcaretosupportandmonitor
individualsintheirongoingrecovery.
Howdowegetmoresubstance-
abusingpeopleintotreatment?
Ithasbeenknownformanyyearsthatthe"treatmentgap”ismassive
—thatis,amongthosewhoneedtreatmentforasubstanceuse
disorder,fewreceiveit.In2011,21.6millionpersonsaged12orolder
neededtreatmentforanillicitdrugoralcoholuseproblem,butonly2.3
millionreceivedtreatmentataspecialtysubstanceabusefacility.
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Reducingthisgaprequiresamultiprongedapproach.Strategiesinclude
increasingaccesstoeffectivetreatment,achievinginsuranceparity
(nowinitsearliestphaseofimplementation),reducingstigma,and
raisingawarenessamongbothpatientsandhealthcareprofessionals
ofthevalueofaddictiontreatment.Toassistphysiciansinidentifying
treatmentneedintheirpatientsandmakingappropriatereferrals,
NIDAisencouragingwidespreaduseofscreening,briefintervention,
andreferraltotreatment(SBIRT)toolsforuseinprimarycaresettings
throughitsNIDAMEDinitiative.SBIRT,whichevidenceshowstobe
effectiveagainsttobaccoandalcoholuse—and,increasingly,against
abuseofillicitandprescriptiondrugs—hasthepotentialnotonlyto
catchpeoplebeforeseriousdrugproblemsdevelop,butalsotoidentify
peopleinneedoftreatmentandconnectthemwithappropriate
treatmentproviders.
Howcanfamilyandfriendsmake
adifferenceinthelifeofsomeone
needingtreatment?
Familyandfriendscanplaycriticalrolesinmotivatingindividualswith
drugproblemstoenterandstayintreatment.Familytherapycanalso
beimportant,especiallyforadolescents.Involvementofafamily
memberorsignificantotherinanindividual'streatmentprogramcan
strengthenandextendtreatmentbenefits.
Wherecanfamilymembersgofor
informationontreatmentoptions?
Tryingtolocateappropriatetreatmentforalovedone,especially
findingaprogramtailoredtoanindividual'sparticularneeds,canbea
difficultprocess.However,therearesomeresourcestohelpwiththis
process.Forexample,NIDA’shandbookSeekingDrugAbuse
Treatment:KnowWhattoAskoffersguidanceinfindingtheright
treatmentprogram.Numerousonlineresourcescanhelplocatealocal
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programorprovideotherinformation,including:
TheSubstanceAbuseandMentalHealthServicesAdministration
(SAMHSA)maintainsaWebsite(www.findtreatment.samhsa.gov)
thatshowsthelocationofresidential,outpatient,andhospital
inpatienttreatmentprogramsfordrugaddictionandalcoholism
throughoutthecountry.Thisinformationisalsoaccessibleby
calling1-800-662-HELP.
TheNationalSuicidePreventionLifeline(1-800-273-TALK)offers
morethanjustsuicideprevention—itcanalsohelpwithahostof
issues,includingdrugandalcoholabuse,andcanconnect
individualswithanearbyprofessional.
TheNationalAllianceonMentalIllness(www.nami.org)andMental
HealthAmerica(www.mentalhealthamerica.net)arealliancesof
nonprofit,self-helpsupportorganizationsforpatientsandfamilies
dealingwithavarietyofmentaldisorders.BothhaveStateand
localaffiliatesthroughoutthecountryandmaybeespecially
helpfulforpatientswithcomorbidconditions.
TheAmericanAcademyofAddictionPsychiatryandtheAmerican
AcademyofChildandAdolescentPsychiatryeachhavephysician
locatortoolspostedontheirWebsitesataaap.organdaacap.org,
respectively.
Faces&VoicesofRecovery(facesandvoicesofrecovery.org),
foundedin2001,isanadvocacyorganizationforindividualsin
long-termrecoverythatstrategizesonwaystoreachouttothe
medical,publichealth,criminaljustice,andothercommunitiesto
promoteandcelebraterecoveryfromaddictiontoalcoholand
otherdrugs.
ThePartnershipatDrugfree.org(drugfree.org)isanorganization
thatprovidesinformationandresourcesonteendruguseand
addictionforparents,tohelpthempreventandinterveneintheir
children’sdruguseorfindtreatmentforachildwhoneedsit.They
offeratoll-freehelplineforparents(1-855-378-4373).
TheAmericanSocietyofAddictionMedicine(asam.org)isa
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societyofphysiciansaimedatincreasingaccesstoaddiction
treatment.TheirWebsitehasanationwidedirectoryofaddiction
medicineprofessionals.
NIDA’sNationalDrugAbuseTreatmentClinicalTrialsNetwork
(drugabuse.gov/about-nida/organization/cctn/ctn)provides
informationforthoseinterestedinparticipatinginaclinicaltrial
testingapromisingsubstanceabuseintervention;orvisit
clinicaltrials.gov.
NIDA’sDrugPubsResearchDisseminationCenter
(drugpubs.drugabuse.gov)providesbooklets,pamphlets,fact
sheets,andotherinformationalresourcesondrugs,drugabuse,
andtreatment.
TheNationalInstituteonAlcoholAbuseandAlcoholism
(niaaa.nih.gov)providesinformationonalcohol,alcoholuse,and
treatmentofalcohol-relatedproblems
(niaaa.nih.gov/search/node/treatment).
Howcantheworkplaceplayarole
insubstanceabusetreatment?
ManyworkplacessponsorEmployeeAssistancePrograms(EAPs)that
offershort-termcounselingand/orassistanceinlinkingemployeeswith
drugoralcoholproblemstolocaltreatmentresources,includingpeer
support/recoverygroups.Inaddition,therapeuticworkenvironments
thatprovideemploymentfordrug-abusingindividualswhocan
demonstrateabstinencehavebeenshownnotonlytopromotea
continueddrug-freelifestylebutalsotoimprovejobskills,punctuality,
andotherbehaviorsnecessaryforactiveemploymentthroughoutlife.
Urinetestingfacilities,trainedpersonnel,andworkplacemonitorsare
neededtoimplementthistypeoftreatment.
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Whatrolecanthecriminaljustice
systemplayinaddressingdrug
addiction?
Itisestimatedthataboutone-halfofStateandFederalprisonersabuse
orareaddictedtodrugs,butrelativelyfewreceivetreatmentwhile
incarcerated.Initiatingdrugabusetreatmentinprisonandcontinuing
ituponreleaseisvitaltobothindividualrecoveryandtopublichealth
andsafety.Variousstudieshaveshownthatcombiningprison-and
community-basedtreatmentforaddictedoffendersreducestheriskof
bothrecidivismtodrug-relatedcriminalbehaviorandrelapsetodrug
use—which,inturn,netshugesavingsinsocietalcosts.A2009study
inBaltimore,Maryland,forexample,foundthatopioid-addicted
prisonerswhostartedmethadonetreatment(alongwithcounseling)in
prisonandthencontinueditafterreleasehadbetteroutcomes
(reduceddruguseandcriminalactivity)thanthosewhoonlyreceived
counselingwhileinprisonorthosewhoonlystartedmethadone
treatmentaftertheirrelease.
Individualswhoentertreatmentunderlegalpressurehave
outcomesasfavorableasthosewhoentertreatmentvoluntarily.
Themajorityofoffendersinvolvedwiththecriminaljusticesystemare
notinprisonbutareundercommunitysupervision.Forthosewith
knowndrugproblems,drugaddictiontreatmentmayberecommended
ormandatedasaconditionofprobation.Researchhasdemonstrated
thatindividualswhoentertreatmentunderlegalpressurehave
outcomesasfavorableasthosewhoentertreatmentvoluntarily.
Thecriminaljusticesystemrefersdrugoffendersintotreatment
throughavarietyofmechanisms,suchasdivertingnonviolent
offenderstotreatment;stipulatingtreatmentasaconditionof
incarceration,probation,orpretrialrelease;andconveningspecialized
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courts,ordrugcourts,thathandledrugoffensecases.Thesecourts
mandateandarrangefortreatmentasanalternativetoincarceration,
activelymonitorprogressintreatment,andarrangeforotherservices
fordrug-involvedoffenders.
Themosteffectivemodelsintegratecriminaljusticeanddrug
treatmentsystemsandservices.Treatmentandcriminaljustice
personnelworktogetherontreatmentplanning—including
implementationofscreening,placement,testing,monitoring,and
supervision—aswellasonthesystematicuseofsanctionsand
rewards.Treatmentforincarcerateddrugabusersshouldinclude
continuingcare,monitoring,andsupervisionafterincarcerationand
duringparole.Methodstoachievebettercoordinationbetween
parole/probationofficersandhealthprovidersarebeingstudiedto
improveoffenderoutcomes.(Formoreinformation,pleasesee
NIDA’sPrinciplesofDrugAbuseTreatmentforCriminalJustice
Populations:AResearch-BasedGuide[revised2012].)
Whataretheuniqueneedsof
womenwithsubstanceuse
disorders?
Gender-relateddrugabusetreatmentshouldattendnotonlyto
biologicaldifferencesbutalsotosocialandenvironmentalfactors,all
ofwhichcaninfluencethemotivationsfordruguse,thereasonsfor
seekingtreatment,thetypesofenvironmentswheretreatmentis
obtained,thetreatmentsthataremosteffective,andthe
consequencesofnotreceivingtreatment.Manylifecircumstances
predominateinwomenasagroup,whichmayrequireaspecialized
treatmentapproach.Forexample,researchhasshownthatphysical
andsexualtraumafollowedbypost-traumaticstressdisorder(PTSD)is
morecommonindrug-abusingwomenthaninmenseekingtreatment.
Otherfactorsuniquetowomenthatcaninfluencethetreatment
processincludeissuesaroundhowtheycomeintotreatment(as
womenaremorelikelythanmentoseektheassistanceofageneralor
23
mentalhealthpractitioner),financialindependence,andpregnancy
andchildcare.
Whataretheuniqueneedsof
pregnantwomenwithsubstance
usedisorders?
Usingdrugs,alcohol,ortobaccoduringpregnancyexposesnotjustthe
womanbutalsoherdevelopingfetustothesubstanceandcanhave
potentiallydeleteriousandevenlong-termeffectsonexposedchildren.
Smokingduringpregnancycanincreaseriskofstillbirth,infant
mortality,suddeninfantdeathsyndrome,pretermbirth,respiratory
problems,slowedfetalgrowth,andlowbirthweight.Drinkingduring
pregnancycanleadtothechilddevelopingfetalalcoholspectrum
disorders,characterizedbylowbirthweightandenduringcognitive
andbehavioralproblems.
Prenataluseofsomedrugs,includingopioids,maycauseawithdrawal
syndromeinnewbornscalledneonatalabstinencesyndrome(NAS).
BabieswithNASareatgreaterriskofseizures,respiratoryproblems,
feedingdifficulties,lowbirthweight,andevendeath.
Researchhasestablishedthevalueofevidence-basedtreatmentsfor
pregnantwomen(andtheirbabies),includingmedications.For
example,althoughnomedicationshavebeenFDA-approvedtotreat
opioiddependenceinpregnantwomen,methadonemaintenance
combinedwithprenatalcareandacomprehensivedrugtreatment
programcanimprovemanyofthedetrimentaloutcomesassociated
withuntreatedheroinabuse.However,newbornsexposedto
methadoneduringpregnancystillrequiretreatmentforwithdrawal
symptoms.Recently,anothermedicationoptionforopioiddependence,
buprenorphine,hasbeenshowntoproducefewerNASsymptomsin
babiesthanmethadone,resultinginshorterinfanthospitalstays.In
general,itisimportanttocloselymonitorwomenwhoaretryingtoquit
druguseduringpregnancyandtoprovidetreatmentasneeded.
24
Whataretheuniqueneedsof
adolescentswithsubstanceuse
disorders?
Adolescentdrugabusershaveuniqueneedsstemmingfromtheir
immatureneurocognitiveandpsychosocialstageofdevelopment.
Researchhasdemonstratedthatthebrainundergoesaprolonged
processofdevelopmentandrefinementfrombirththroughearly
adulthood.Overthecourseofthisdevelopmentalperiod,ayoung
person’sactionsgofrombeingmoreimpulsivetobeingmorereasoned
andreflective.Infact,thebrainareasmostcloselyassociatedwith
aspectsofbehaviorsuchasdecision-making,judgment,planning,and
self-controlundergoaperiodofrapiddevelopmentduringadolescence
andyoungadulthood.
Adolescentdrugabuseisalsooftenassociatedwithotherco-occurring
mentalhealthproblems.Theseincludeattention-deficithyperactivity
disorder(ADHD),oppositionaldefiantdisorder,andconductproblems,
aswellasdepressiveandanxietydisorders.
Adolescentsarealsoespeciallysensitivetosocialcues,withpeer
groupsandfamiliesbeinghighlyinfluentialduringthistime.Therefore,
treatmentsthatfacilitatepositiveparentalinvolvement,integrateother
systemsinwhichtheadolescentparticipates(suchasschooland
athletics),andrecognizetheimportanceofprosocialpeerrelationships
areamongthemosteffective.Accesstocomprehensiveassessment,
treatment,casemanagement,andfamily-supportservicesthatare
developmentally,culturally,andgender-appropriateisalsointegral
whenaddressingadolescentaddiction.
Medicationsforsubstanceabuseamongadolescentsmayincertain
casesbehelpful.Currently,theonlyaddictionmedicationsapproved
byFDAforpeopleunder18areover-the-countertransdermalnicotine
skinpatches,chewinggum,andlozenges(physicianadviceshouldbe
soughtfirst).Buprenorphine,amedicationfortreatingopioidaddiction
25
thatmustbeprescribedbyspeciallytrainedphysicians,hasnotbeen
approvedforadolescents,butrecentresearchsuggestsitcouldbe
effectiveforthoseasyoungas16.Studiesareunderwaytodetermine
thesafetyandefficacyofthisandothermedicationsforopioid-,
nicotine-,andalcohol-dependentadolescentsandforadolescentswith
co-occurringdisorders.
Aretherespecificdrugaddiction
treatmentsforolderadults?
Withtheagingofthebabyboomergeneration,thecompositionofthe
generalpopulationischangingdramaticallywithrespecttothenumber
ofolderadults.Suchachange,coupledwithagreaterhistoryof
lifetimedruguse(thanpreviousoldergenerations),differentcultural
normsandgeneralattitudesaboutdruguse,andincreasesinthe
availabilityofpsychotherapeuticmedications,isalreadyleadingto
greaterdrugusebyolderadultsandmayincreasesubstanceuse
problemsinthispopulation.Whilesubstanceabuseinolderadults
oftengoesunrecognizedandthereforeuntreated,researchindicates
thatcurrentlyavailableaddictiontreatmentprogramscanbeas
effectiveforthemasforyoungeradults.
Canapersonbecomeaddictedto
medicationsprescribedbya
doctor?
Yes.Peoplewhoabuseprescriptiondrugs—thatis,takingthemina
manneroradoseotherthanprescribed,ortakingmedications
prescribedforanotherperson—riskaddictionandotherserioushealth
consequences.Suchdrugsincludeopioidpainrelievers,stimulants
usedtotreatADHD,andbenzodiazepinestotreatanxietyorsleep
disorders.Indeed,in2010,anestimated2.4millionpeople12orolder
metcriteriaforabuseofordependenceonprescriptiondrugs,the
secondmostcommonillicitdruguseaftermarijuana.Tominimize
26
theserisks,aphysician(orotherprescribinghealthprovider)should
screenpatientsforpriororcurrentsubstanceabuseproblemsand
assesstheirfamilyhistoryofsubstanceabuseoraddictionbefore
prescribingapsychoactivemedicationandmonitorpatientswhoare
prescribedsuchdrugs.Physiciansalsoneedtoeducatepatientsabout
thepotentialriskssothattheywillfollowtheirphysician’sinstructions
faithfully,safeguardtheirmedications,anddisposeofthem
appropriately.
Isthereadifferencebetween
physicaldependenceand
addiction?
Yes.Addiction—orcompulsivedrugusedespiteharmfulconsequences
—ischaracterizedbyaninabilitytostopusingadrug;failuretomeet
work,social,orfamilyobligations;and,sometimes(dependingonthe
drug),toleranceandwithdrawal.Thelatterreflectphysicaldependence
inwhichthebodyadaptstothedrug,requiringmoreofittoachievea
certaineffect(tolerance)andelicitingdrug-specificphysicalormental
symptomsifdruguseisabruptlyceased(withdrawal).Physical
dependencecanhappenwiththechronicuseofmanydrugs—
includingmanyprescriptiondrugs,eveniftakenasinstructed.Thus,
physicaldependenceinandofitselfdoesnotconstituteaddiction,but
itoftenaccompaniesaddiction.Thisdistinctioncanbedifficultto
discern,particularlywithprescribedpainmedications,forwhichthe
needforincreasingdosagescanrepresenttoleranceoraworsening
underlyingproblem,asopposedtothebeginningofabuseoraddiction.
Howdoothermentaldisorders
coexistingwithdrugaddiction
affectdrugaddictiontreatment?
Drugaddictionisadiseaseofthebrainthatfrequentlyoccurswith
27
othermentaldisorders.Infact,asmanyas6in10peoplewithanillicit
substanceusedisorderalsosufferfromanothermentalillness;and
ratesaresimilarforusersoflicitdrugs—i.e.,tobaccoandalcohol.For
theseindividuals,oneconditionbecomesmoredifficulttotreat
successfullyasanadditionalconditionisintertwined.Thus,people
enteringtreatmenteitherforasubstanceusedisorderorforanother
mentaldisordershouldbeassessedfortheco-occurrenceoftheother
condition.Researchindicatesthattreatingboth(ormultiple)illnesses
simultaneouslyinanintegratedfashionisgenerallythebesttreatment
approachforthesepatients.
Istheuseofmedicationslike
methadoneandbuprenorphine
simplyreplacingoneaddiction
withanother?
No.Buprenorphineandmethadoneareprescribedoradministered
undermonitored,controlledconditionsandaresafeandeffectivefor
treatingopioidaddictionwhenusedasdirected.Theyareadministered
orallyorsublingually(i.e.,underthetongue)inspecifieddoses,and
theireffectsdifferfromthoseofheroinandotherabusedopioids.
Heroin,forexample,isofteninjected,snorted,orsmoked,causingan
almostimmediate"rush,"orbriefperiodofintenseeuphoria,that
wearsoffquicklyandendsina"crash."Theindividualthen
experiencesanintensecravingtousethedrugagaintostopthecrash
andreinstatetheeuphoria.
Thecycleofeuphoria,crash,andcraving—sometimesrepeatedseveral
timesaday—isahallmarkofaddictionandresultsinseverebehavioral
disruption.Thesecharacteristicsresultfromheroin’srapidonsetand
shortdurationofactioninthebrain.
28
Asusedinmaintenancetreatment,methadoneandbuprenorphine
arenotheroin/opioidsubstitutes.
Incontrast,methadoneandbuprenorphinehavegradualonsetsof
actionandproducestablelevelsofthedruginthebrain.Asaresult,
patientsmaintainedonthesemedicationsdonotexperiencearush,
whiletheyalsomarkedlyreducetheirdesiretouseopioids.
Ifanindividualtreatedwiththesemedicationstriestotakeanopioid
suchasheroin,theeuphoriceffectsareusuallydampenedor
suppressed.Patientsundergoingmaintenancetreatmentdonot
experiencethephysiologicalorbehavioralabnormalitiesfromrapid
fluctuationsindruglevelsassociatedwithheroinuse.Maintenance
treatmentssavelives—theyhelptostabilizeindividuals,allowing
treatmentoftheirmedical,psychological,andotherproblemssothey
cancontributeeffectivelyasmembersoffamiliesandofsociety.
Wheredo12-steporself-help
programsfitintodrugaddiction
treatment?
Self-helpgroupscancomplementandextendtheeffectsof
professionaltreatment.Themostprominentself-helpgroupsarethose
affiliatedwithAlcoholicsAnonymous(AA),NarcoticsAnonymous(NA),
andCocaineAnonymous(CA),allofwhicharebasedonthe12-step
model.Mostdrugaddictiontreatmentprogramsencouragepatientsto
participateinself-helpgrouptherapyduringandafterformal
treatment.Thesegroupscanbeparticularlyhelpfulduringrecovery,
offeringanaddedlayerofcommunity-levelsocialsupporttohelp
peopleachieveandmaintainabstinenceandotherhealthylifestyle
behaviorsoverthecourseofalifetime.
29
Canexerciseplayaroleinthe
treatmentprocess?
Yes.Exerciseisincreasinglybecomingacomponentofmanytreatment
programsandhasproveneffective,whencombinedwithcognitive-
behavioraltherapy,athelpingpeoplequitsmoking.Exercisemayexert
beneficialeffectsbyaddressingpsychosocialandphysiologicalneeds
thatnicotinereplacementalonedoesnot,byreducingnegative
feelingsandstress,andbyhelpingpreventweightgainfollowing
cessation.Researchtodetermineifandhowexerciseprogramscan
playasimilarroleinthetreatmentofotherformsofdrugabuseis
underway.
Howdoesdrugaddiction
treatmenthelpreducethespread
ofHIV/AIDS,HepatitisC(HCV),
andotherinfectiousdiseases?
Drug-abusingindividuals,includinginjectingandnon-injectingdrug
users,areatincreasedriskofhumanimmunodeficiencyvirus(HIV),
hepatitisCvirus(HCV),andotherinfectiousdiseases.Thesediseases
aretransmittedbysharingcontaminateddruginjectionequipmentand
byengaginginriskysexualbehaviorsometimesassociatedwithdrug
use.EffectivedrugabusetreatmentisHIV/HCVpreventionbecauseit
reducesactivitiesthatcanspreaddisease,suchassharinginjection
equipmentandengaginginunprotectedsexualactivity.Counseling
thattargetsarangeofHIV/HCVriskbehaviorsprovidesanaddedlevel
ofdiseaseprevention.
DrugabusetreatmentisHIVandHCVprevention.
30
Injectiondruguserswhodonotentertreatmentareuptosixtimes
morelikelytobecomeinfectedwithHIVthanthosewhoenterand
remainintreatment.Participationintreatmentalsopresents
opportunitiesforHIVscreeningandreferraltoearlyHIVtreatment.In
fact,recentresearchfromNIDA’sNationalDrugAbuseTreatment
ClinicalTrialsNetworkshowedthatprovidingrapidonsiteHIVtestingin
substanceabusetreatmentfacilitiesincreasedpatients’likelihoodof
beingtestedandofreceivingtheirtestresults.HIVcounselingand
testingarekeyaspectsofsuperiordrugabusetreatmentprogramsand
shouldbeofferedtoallindividualsenteringtreatment.Greater
availabilityofinexpensiveandunobtrusiverapidHIVtestsshould
increaseaccesstotheseimportantaspectsofHIVpreventionand
treatment.