In contrast, in very early recovery, many people are effectively “white-knuckling” it, holding on to their abstinence for dear life. It is in the days, weeks, and few months immediately after the cessation of using, whether the person went through professional treatment or not, that he or she is especially vulnerable to relapse.
It may come as a surprise to a lot of people, but addiction treatment is as effective as treatment for other chronic medical conditions. In other words, addiction treatment has basically the same outcomes—the same rates of success and relapse—as treatment for asthma, diabetes, congestive heart failure, high blood pressure, low-back pain, and other chronic medical conditions.
Effective treatment for addiction varies depending on severity, the types of drugs involved, and the characteristics of the patient. The best treatment programs provide a combination of therapies and other biopsychosocial services.
Since 1999, the National Institute on Drug Abuse, part of the National Institutes of Health, has maintained the following thirteen principles of effective treatment for drug addiction:
1 No single treatment is appropriate for all individuals.
2 Treatment needs to be readily available.
3 Effective treatment attends to multiple needs of the individual, not just his or her drug use.
4 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.
5 Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
6 Individual or group counseling and other behavioral therapies are critical components of effective treatment for addiction.
7 Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
8 Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
9 Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
10 Treatment does not need to be voluntary to be effective.
11 Possible drug use during treatment must be monitored continuously.
12 Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection.
13 Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.
There are many types of behaviorally oriented therapies, and for addiction therapists or students in addiction counseling programs, these are a primary focus of treatment. This is what we refer to as “talk therapy.” Talk therapy can take a variety of forms and orientations, including, but not limited to individual and group counseling, family therapy, educational lectures, cognitive-behavioral therapy (where the specific focus is on helping people to identify and change their thought processes and problematic behaviors), and psychotherapy.
A point of clarification: Most of the time, counseling and therapy essentially refer to the same thing. However, there are some distinctions between counseling and “psychotherapy,” with which it is helpful to be familiar. In the context of behavioral health (which includes addiction), “counseling” generally means a relatively brief treatment process that focuses on specific behavior. It often targets a particular symptom or problematic situation and offers suggestions and advice for dealing with it. Psychotherapy is typically (though not necessarily) a longer-term treatment that is oriented more toward gaining insight into mental and emotional challenges by focusing on the person’s thought processes and way of being in the world rather than on specific problems.
In clinical practice there is frequent overlap between counseling and psychotherapy. A therapist may provide counseling for specific situations and a counselor may function in a psychotherapeutic manner. As a generalization however, psychotherapy requires more skill than simple counseling, and is conducted by professionals trained to practice psychotherapy, such as psychiatrists, trained counselors, social workers, and psychologists. While a psychotherapist is qualified to provide counseling, a counselor may or may not possess the necessary training and skills to provide psychotherapy. These differences notwithstanding, for simplicity, I will use the terms “counseling” and “therapy” interchangeably.
Addiction treatment can involve the following levels of care: medical detoxification, inpatient rehabilitation, non-intensive outpatient treatment, intensive outpatient treatment, short-term residential treatment, and long-term residential treatment. All of these levels of care include various forms of talk therapy/counseling, addiction- and recovery-specific education, drug screening/testing to verify abstinence, and medication. Medications in addiction treatment can be those prescribed for detoxification and co-occurring psychiatric conditions, as well as agonist maintenance therapy and antagonist maintenance therapy.
An agonist is a molecule that combines with a receptor on a cell to trigger a physiological reaction. I liken the process to turning on an appliance through electricity. When you plug a blender into an electrical outlet, the plug is the agonist and the outlet is the receptor. The brain contains receptors. When certain drugs and medications fill those receptors, they trigger specific reactions. Agonist therapy includes medications like methadone and Suboxone (though technically, Suboxone is a partial opioid agonist—more about that later) that are designed to substitute for opiates/opioids, whether illicit or legally prescribed, on which people have become dependent (this will be discussed at length in Chapter Five). This notwithstanding, these medications have their own addictive potential and their use should be carefully structured and supervised.
There is also antagonist treatment. An antagonist is the opposite of an agonist. It is a medication that acts against and blocks the mind- and mood-altering effects of specific substances. Agonists and antagonists are key players in the chemistry of the nervous system. An example of a medication antagonist is naltrexone. This is used to block the effects of opiates and alcohol. I will also discuss these medications at length in Chapter Five.
In addiction treatment we see a lot of people who have psychiatric issues along with their addiction. There is a lot of depression and no small amount of bipolar symptomology among people with addiction. Addiction treatment providers also see a lot of anxiety disorders. Sometimes alcohol and other drugs are the primary cause of these psychiatric symptoms. In many others, the addiction contributes to and exacerbates co-occurring mental health problems that began prior to the initiation of substance use. Moreover, the existence of psychiatric issues also commonly complicates and exacerbates one’s active addiction.
When the field of addiction treatment was young, “sequential treatment” was typical. Unfortunately, what used to happen was that psychiatrists, psychologists, and therapists often refused to work with patients who were actively using alcohol or other drugs. At the same time, a lot of people in addiction treatment were uncomfortable working with addicts who also had psychiatric issues. As a result, nobody wanted to work with these patients with co-occurring addiction and psychiatric issues and they often fell between the cracks of the treatment and service delivery system. We have since learned that integrated and concurrent treatment in which patients’ addiction, mental health, and medical needs are addressed simultaneously is the most effective approach.
Behavioral therapies offer strategies for dealing with cravings, teach patients ways to enhance their coping capacity and prevent relapse, and help them deal with relapse should it occur. Addicts often suffer severe cravings. And unless they receive some form of treatment to help them learn how to manage cravings and withstand them, many addicts feel