Perhaps the most fundamental of these is instilling and reinforcing in patients the knowledge that cravings will pass because they come in bursts and spurts. Even though, for the person experiencing an intense desire to use, cravings can feel like they will last forever, they are always temporary. It is critical to teach this information because addicted people are not aware of it. The solution to cravings is to develop ways to ride them out. This often involves distraction, such as listening to music, going for a walk, going to a movie, or calling friends. This is one of the many areas where participation in mutual-aid/support programs, twelve-step programs in particular, can be extremely valuable. When people in twelve-step recovery are struggling, they can call their sponsor. They can go to a meeting; they can talk with members of their support group who have been through very similar experiences.
Why can’t addicts quit on their own? In the beginning, many addicts believe they can and from time to time they try to stop. For most addicts, discontinuing using means going through detoxification, the process of substances leaving the body and brain. Depending upon the substance and how long and how much someone used, the withdrawal symptoms people experience during detox can be agonizingly painful to potentially lethal. For example, opiate withdrawal from opiates/opioids like heroin, Vicodin, and OxyContin causes a withdrawal syndrome that is horribly painful, but it’s not dangerous (opioid overdose is dangerous but opioid withdrawal usually is not). However, withdrawal from sedative-hypnotics such as Xanax and Valium, and from alcohol, is extremely dangerous because people can die from DTs (delirium tremens) and seizures.
It’s important to not confuse how addicting specific substances are with the severity of the withdrawal syndrome associated with them. These are entirely different areas. For example, stimulants like cocaine and crystal meth are very addictive, but their withdrawal syndrome is minimal compared to opiates, sedative-hypnotics, and alcohol. To give you an idea of why, think of the neurons in your brain as little springs—alcohol and the sedatives keep the springs down, because they’re depressants. If you let a spring up really quickly, it bounces all over the room, but if you let it up slowly, you can control it. When people suddenly stop drinking, their neurons are firing like crazy (the springs are bouncing uncontrollably), and that can result in physiological instability, up to and including seizures.
But even when addicts are able to stop using—whether they detox on their own or through a medically supervised detoxification regime where medications are administered to make them safe and somewhat less uncomfortable—without treatment and/or working a program of recovery, the vast majority fail to achieve long-term abstinence. Detox is merely ridding the body of the physical presence of substances. It is not addiction treatment, though many addicts go through detox as a prerequisite to treatment. A lot of people go through detox and then refuse to attend treatment.
Medical detoxification is only the first step. A lot of addicted people come in, especially to a medical facility, and say, “I’m here to get detoxed,” or “I want to get detoxed.” Once they’ve been detoxed I say, “I now want to set you up to go see a counselor or therapist to go over addiction treatment.” Their response will sometimes be, “No, I’m not interested in that; I only came to be detoxed.” Addicts come in all stripes. We have patients at our clinic who come in for detox and we never see them again. And there are those who come back six months or a year later for detox again. They won’t meet with a counselor, won’t get any kind of treatment, and don’t establish any real abstinence, nevermind recovery. And we don’t see them again until the next time they need detox.
I always tell people that even when addicts can stop using, the problem is they don’t stay stopped. They stop for a day or two, or a week; they stop for two weeks, or even a month. And then they go right back to using again.
What defines success in addiction treatment? For people who complete a treatment program, one basic definition of successful treatment is no substance use and no criminality for a minimum of two years. Positive outcomes are correlated with adequate lengths of treatment. Success depends in part on whether patients remain in treatment long enough to experience and integrate its full benefits. As a generalization, the longer people remain in treatment, the better their chances of remaining abstinent and achieving recovery. And whether a person stays in treatment depends on multiple factors related to both the individual and the program.
Important individual factors include personal motivation to change, family dynamics, social supports, medical insurance, and other financial resources, as well as outside pressure to stay in treatment. Such factors include the criminal justice system and the Child Protective Services system, where the options are often either addiction treatment or incarceration, or potential loss of the custody of one’s children. Other external motivating factors are the person’s partner/spouse/family and his or her employer. All of these variables can play a role in whether the person enters and remains in treatment long enough to complete it or not.
These individual variables assume many different configurations, consistent with the diversity of addiction treatment patients. This diversity ranges from (for example) the previously high-functioning Beverly Hills attorney who is abusing alcohol to the schizophrenic high school dropout who is shooting heroin and living under the freeway overpass.
The Beverly Hills attorney is the head of his law firm, is married and has two kids, went to Harvard, and makes a million dollars a year in his law practice. One day, he comes home and an intervention is waiting for him. His wife, his law partner, and his kids are all sitting there with a trained interventionist, and they all say in various ways, “Listen, we love you, but we don’t love your drinking.” You know how the rest of it goes: “If you keep drinking we’re going to leave, we’re going to turn you over to the state bar, you’re going to lose your law license, we’re going to remove you from the law firm, and all these bad things are going to happen unless you go into a treatment program.”
Then there’s a heroin addict with an eighth-grade education who has schizophrenia, who contracted HIV from intravenous drug use, has no job skills, and is hearing voices. How do you compare these two situations? Obviously, there are many significant differences between these two people.
There are also treatment program factors related to retention. It is essential for counselors to establish positive therapeutic relationships with clients as early in treatment as possible, and ensure that a treatment plan is developed and followed in collaboration with each client. Clients also need information and psychoeducation regarding what to expect both structurally and experientially during treatment. Medical, psychiatric, and case management services should be available concurrent with psychosocial addiction treatment, and transitions to step-down continuing care or aftercare need to be agreed upon well in advance and be as seamless as circumstances allow.
Something that comes as a surprise to a lot of people is that individuals who enter treatment under legal pressure have outcomes that are just as successful as those who enter treatment voluntarily. That seems counterintuitive, doesn’t it? We tend to think that somebody “forced” into treatment because the court has given him or her the choice of treatment or jail would rebel against the process. Of course some people do rebel against the structure and process of addiction treatment—but that happens regardless of whether their motivation is primarily internal or external.
Interestingly, once many people who are mandated to enter treatment are exposed to recovery, positive things happen, and a lot of people begin to turn their lives around. I tell patients that “I don’t care all that much about the reason why you’re here. I don’t care if you’re here because your wife or your husband or your parents sent you, or if it’s the court or Child Protective Services that made you come, as long as you’re here. If you want to do it for your wife or whomever, do it for her, just as long as you’re here, and then we’ll see what happens after that.”
Here’s a critical point for aspiring addiction treatment professionals to consider: not everybody wants to stop using. That’s something you need to learn right now so your expectations can be set realistically, and you don’t burn out from the frustration and disappointment of not succeeding with all of them. Often, it’s