Substance Use Disorders: Treatment
Author: Eric K. Mason
Substance use disorders/addictions are relatively common, affecting some 23.7 million people in the United States (Maxem & Ward, 1995). Indeed, the use of addictive substances is prevalent in most societies. From nicotine and caffeine to cocaine and heroin, it has been documented that people have been using drugs to alter their mood, mind, and consciousness for thousands of years (Austin, 1979). Although some people appear to be able to use addictive substances in moderation, those who begin to use drugs obsessively and become addicted often face many negative (often disastrous consequences), such as health problems, family strife, legal troubles, and financial ruin.
Despite such negative consequences, those with substance use disorders usually find it incredibly hard to stop using drugs on their own. As such, it is typically recommended that they seek out assistance from professionals. In the following paper, I will discuss the various treatment options available for treatment of substance use disorders, such as outpatient counseling, inpatient treatment (rehab), pharmacological therapy, and self-help groups (Parachin, 2003).
The first step in dealing with substance use disorders is to determine the level of treatment that is needed or available. This can be done by completing a substance use assessment. Trained addiction professionals often will give a semi-structured interview, in which they are able to determine the appropriate level of treatment. Information gleaned from such interviews would include the client’s substance use history, such as age of onset, amount of drug used, frequency, type of substance used, periods of sobriety, relapse history, as well as prior treatment history (Parachin, 2003).
Other simple assessment tools are available to help determine what level of treatment is necessary. Such tools may be administered by non-professionals or even self-administered by clients. Examples include the CAGE, the ASI, and the 4 P’s (Evans & Sullivan, 2001).
The CAGE is an acronym that stands for the Cut down, Annoyed, Guilty, and Eye-opener. It is administered by asking the client the following. ‘Have you ever felt the need to cut down on your drug use?’ ‘Have you ever felt annoyed by others complaining about your drug use?’ ‘Have you ever felt guilty about your drug use?’ ‘Do you often need an eye-opener (i.e., a drink or drug first thing in the morning in order to start your day)?’ One or two positive answers is considered a positive test (Evans & Sullivan, 2001).
The (ASI) Addiction Severity Index is a 150 question questionnaire, which measures the impact of substances on multiple areas of the client’s life, such as degree of legal problems, financial consequences, familial troubles, and health complications. The 4 P’s is specifically designed for women and is administered by asking the client the following: ‘Do either of your parents have a drug or alcohol problem?’ ‘Have you ever used drugs or alcohol when you your pregnant?’ ‘Has drug or alcohol use caused you any problems in the past?’ (Evans & Sullivan, 2001).
In addition to interviewing the client, counselors should consider the possibility of conducting collateral interviews with the client’s family (of course, the client would have to give permission to do this), since people with substance disorder are inclined to deny or minimize their substance use. Indeed, people with substance use disorders are often ashamed due to the stigma associated with it (Evans & Sullivan, 2001).
Inpatient treatment for drug addiction (often referred to as rehab) is appropriate for those who have been determined through the assessment process to have true drug addiction or substance use disorder. Inpatient treatment is most effective for those truly addicted, as it isolates clients from their home environment where they are more likely to experience triggers. Triggers are stimuli that cause a person to crave a drug, as they remind the person of drug use—much like the phenomenon of classical conditioning. Triggers often include certain people (friends or family with whom the person used drugs), places (bars, certain neighborhoods, etc.), and things (familiar objects associated with drug use) that trigger an urge to use drugs (Parachin, 2003).
The ideal amount of time for inpatient treatment is 90 days. Relapse rates drop from approximately 70% to 50% when comparing treatment of 30 days to 90 days. (Peele, 2010). During inpatient treatment substance use disorders should be treated alongside mental health disorders simultaneously. Failure to address mental health concerns is likely to increase the risk of relapse, as it is well known that people with mental illness may use drugs as a means of self-medicating. An intensive daily mix of group therapy, individual therapy, and educational groups are often used in inpatient treatment to treat those with substance use disorders (Evans & Sullivan, 2001).
When a person first comes in to inpatient treatment, the clinician needs to determine if detox is required. Detox is the process by which a person gradually reduces their intake of drugs—either for medically necessary reasons or to make the person more comfortable while going through drug withdrawals. For some substances, such as alcohol or benzodiazepines, a medically supervised detox may be necessary, since detoxing from them may be dangerous or even life threatening. Other substances, such as opiates or cocaine, may require a medical detox, as well. Although not life threatening, the use of medications to ease the withdrawal processes will make the person much more comfortable and more likely not to leave treatment early (Maxem & Ward, 1995).
After completing inpatient treatment, continuing aftercare in outpatient treatment is essential in order to ensure long-term sobriety. Ideally, aftercare would include a mix of individual counseling, group therapy, and self-help groups. Furthermore, ongoing psychiatric care may be necessary for those with mental disorders. Below I will discuss the most effective outpatient treatment methods (Parachin, 2003).
As clients leave inpatient treatment, they will have to readjust to their lives sober, as well as deal with, perhaps, the damage their addiction caused. This includes damaged relationships, financial problems, or legal troubles. As such, clients in early recovery may need a great deal of support working through these issues. Person-centered counseling is advisable for general, supportive counseling. Other therapeutic approaches that are effective include CBT, motivational interviewing, cue exposure, and behavioral self-control training (Corey, 2001).
Self-groups, such as NA and AA, have been a mainstay in the treatment of addiction. A criticism of such groups is the influence of religion and spirituality. Other self-help groups which are similar, but don’t involve religion or spirituality include Secular Organizations for Sobriety and Smart Recovery. Self-help groups offer clients a network of social support and fellowship that has shown useful in assisting clients to stay in recovery from drugs and alcohol. Self-help groups are free, which is also very attractive to those with limited resources. Although self-help groups are recommended, they do not equate to treatment. Self-help groups are far more effective when they serve as a supplement to therapy (Maxem & Ward, 1995).
Medications for the treatment substance use disorders may be considered for two different purposes—detox or long-term maintenance. As mentioned earlier, medications for detox are used in such cases when detoxing may be dangerous or very unpleasant. Medications may also be used for long-term maintenance. These medications may be antagonists (preventing a drug from having the desired effect) or agonists (causing a similar effect to a drug, but in a controlled manner), while others may cause a very unpleasant reaction if the certain drug is consumed (Maxem & Ward, 1995).
For example, Baclofen is an antagonist medication which eliminates the high associated with cocaine (if it is taken before cocaine is consumed). Another antagonist is Naltrexone which blocks the effect of heroin or other opiates. Antabuse is an antagonist medication that causes an allergic reaction when alcohol is consumed. Again, it must be taken daily to have an effect. Other medications, such as agonists, with long half lives are sometimes used to reduce the cravings associated with a drug. For example, methadone is a medication which prevents one from experiencing cravings opiates for up to 24 hours. Methadone works on the brain similarly to opiates, but not as intensely. Some argue the methadone simply replaces one addiction for another, rather than dealing with the root of the addiction (Maxem & Ward, 1995).
Substance use disorders wreak havoc on the lives of those affected. They have detrimental effects on finances, employment, social relationships, and family connections. There are multiple treatment options available for those with substance use disorders. However, substance use disorders remain difficult to treat with mostly low success rates. Indeed, relapse is a feature of substance use disorders and doesn’t necessarily point towards a failure of treatment. A combination of therapies is usually the most ideal option. This includes individual counseling (CBT and motivational interviewing), group therapy, medications, and self-help groups. Often inpatient treatment is recommended, followed by outpatient treatment.
Indeed, substance use disorders can be a lifelong struggle for those affected. Since addiction is difficult to overcome, prevention may be a more practical approach to dealing with the problem of addiction. Early intervention may be the key to ensuring that those with problematic drug use do not develop a lifelong substance use disorder.