Treatment Approaches for Drug Addiction

Drug addiction is a complex illness characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. While the path to drug addiction begins with the voluntary act of taking drugs, over time a person’s ability to choose not to do so becomes compromised, and seeking and consuming the drug becomes compulsive. This behavior results largely from the effects of prolonged drug exposure on brain functioning. Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior.

Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is typically a chronic disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.

Too often, addiction goes untreated: According to SAMHSA’s National Survey on Drug Use and Health (NSDUH), 23.2 million persons (9.4 percent of the U.S. population) aged 12 or older needed treatment for an illicit drug or alcohol use problem in 2007. Of these individuals, 2.4 million (10.4 percent of those who needed treatment) received treatment at a specialty facility (i.e., hospital, drug or alcohol rehabilitation or mental health center). Thus, 20.8 million persons (8.4 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive it. These estimates are similar to those in previous years.

Principles of Effective Treatment

Scientific research since the mid-1970s shows that treatment can help patients addicted to drugs stop using, avoid relapse, and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment programs:

  • Addiction is a complex but treatable disease that affects brain function and behavior.
  • No single treatment is appropriate for everyone.
  • Treatment needs to be readily available.
  • Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
  • Remaining in treatment for an adequate period of time is critical.
  • Counseling – individual and/or group – and other behavioral therapies are the most commonly used forms of drug abuse treatment.
  • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
  • An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
  • Many drug-addicted individuals also have other mental disorders.
  • Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.
  • Treatment does not need to be voluntary to be effective.
  • Drug use during treatment must be monitored continuously, as lapses during treatment do occur.
  • Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.
  • Effective Treatment Approaches

    Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that often begins with detoxification, followed by treatment and relapse prevention. Easing withdrawal symptoms can be important in the initiation of treatment; preventing relapse is necessary for maintaining its effects.

    And sometimes, as with other chronic conditions, episodes of relapse may require a return to prior treatment components. A continuum of care that includes a customized treatment regimen – addressing all aspects of an individual’s life, including medical and mental health services—and followup options (e.g., community – or family – based recovery support systems) can be crucial to a person’s success in achieving and maintaining a drug free lifestyle.

    Medications

    Medications can be used to help with different aspects of the treatment process.

    Withdrawal

    Medications offer help in suppressing withdrawal symptoms during detoxification. However, medically assisted detoxification is not in itself “treatment”—it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.

    Treatment

    Medications can be used to help reestablish normal brain function and to prevent relapse and diminish cravings. Currently, we have medications for opioids (heroin, morphine), tobacco (nicotine), and alcohol addiction and are developing others for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. Most people with severe addiction problems, however, are polydrug users (users of more than one drug) and will require treatment for all of the substances that they abuse.

    Opioids: Methadone, buprenorphine and, for some individuals, naltrexone are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone works by blocking the effects of heroin or other opioids at their receptor sites and should only be used in patients who have already been detoxified. Because of compliance issues, naltrexone is not as widely used as the other medications. All medications help patients disengage from drug seeking and related criminal behavior and become more receptive to behavioral treatments.

    Tobacco: A variety of formulations of nicotine replacement therapies now exist—including the patch, spray, gum, and lozenges – that are available over the counter. In addition, two prescription medications have been FDA-approved for tobacco addiction: bupropion and varenicline. They have different mechanisms of action in the brain, but both help prevent relapse in people trying to quit. Each of the above medications is recommended for use in combination with behavioral treatments, including group and individual therapies, as well as telephone quitlines.

    Alcohol: Three medications have been FDA-approved for treating alcohol dependence: naltrexone, acamprosate, and disulfiram. A fourth, topiramate, is showing encouraging results in clinical trials. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some but not all patients—this is likely related to genetic differences. Acamprosate is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (an unpleasant or uncomfortable emotional state, such as depression, anxiety, or irritability). It may be more effective in patients with severe dependence. Disulfiram interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. Compliance can be a problem, but among patients who are highly motivated, disulfiram can be very effective.

    Behavioral Treatments

    Behavioral treatments help patients engage in the treatment process, modify their attitudes and behaviors related to drug abuse, and increase healthy life skills. These treatments can also enhance the effectiveness of medications and help people stay in treatment longer. Treatment for drug abuse and addiction can be delivered in many different settings using a variety of behavioral approaches. Outpatient behavioral treatment encompasses a wide variety of programs for patients who visit a clinic at regular intervals. Most of the programs involve individual or group drug counseling. Some programs also offer other forms of behavioral treatment such as:

    • Cognitive-behavioral therapy, which seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.
    • Multidimensional family therapy, which was developed for adolescents with drug abuse problems – as well as their families – addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.
    • Motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment.
    • Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.

    Residential treatment programs can also be very effective, especially for those with more severe problems. For example, therapeutic communities (TCs) are highly structured programs in which patients remain at a residence, typically for 6 to 12 months. TCs differ from other treatment approaches principally in their use of the community-treatment staff and those in recovery – as a key agent of change to influence patient attitudes, perceptions, and behaviors associated with drug use. Patients in TCs may include those with relatively long histories of drug addiction, involvement in serious criminal activities, and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children. The focus of the TC is on the resocialization of the patient to a drug-free, crime-free lifestyle.

    Treatment Within the Criminal Justice System

    Treatment in a criminal justice setting can succeed in preventing an offender’s return to criminal behavior, particularly when treatment continues as the person transitions back into the community. Studies show that treatment does not need to be voluntary to be effective.

    Other Information Sources

    For Drug & Alcohol Treatment Centers near you visit us here or call 844-747-6542.

    For more detailed information on treatment approaches for drug addiction and examples of specific programs proven effective through research, view NIDA’s Principles of Drug Addiction Treatment: A Research-Based Guide at www.nida.nih.gov/PODAT/PODATIndex.html (English).

    For information about treatment for drug abusers in the criminal justice system, view NIDA’s Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide at www.drugabuse.gov/PODAT_CJ.

    Data are from the National Survey on Drug Use and Health (formerly known as the National Household Survey on Drug Abuse), which is an annual survey of Americans age 12 and older conducted by the Substance Abuse and Mental Health Services Administration. This survey is available online at www.samhsa.gov and from NIDA at 877-643-2644.

Principles of Effective Treatment

1.Addiction is a complex but treatable disease that affects brain function and behavior.


Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences.

2.No single treatment is appropriate for everyone.

Treatment varies depending on the type of drug and the characteristics of the patients. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.

3.Treatment needs to be readily available.

Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.

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4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.

To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture.

5.Remaining in treatment for an adequate period of time is critical.

The appropriate duration for an individual depends on the type and degree of the patient’s problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.

6.Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment.

Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence.

7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

For example, methadone, buprenorphine, and naltrexone (including a new long-acting formulation) are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Acamprosate, disulfiram, and naltrexone are medication approved for treating alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (available as patches, gum, lozenges, or nasal spray) or an oral medication (such as bupropion or varenicline) can be an effective component of treatment when part of a comprehensive behavioral treatment program.

8.An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.

A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person’s changing needs.

9. Many drug-addicted individuals also have other mental disorders.

Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.

10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.

Although medically assisted detoxification can safely manage theacute physical symptoms of withdrawal and can, for some, pave the way for effective long-term addiction treatment, detoxification alone is rarely sufficient to helpaddicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment following detoxification. Motivation enhancement and incentive strategies, begun at initial patient intake, can improve treatment engagement.

11. Treatment does not need to be voluntary to be effective.

Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatmentent, retention rates, and the ultimate success of drug treatment interventions.

12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur.

Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs.

13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can facilitate adherence to other medical treatments. Substance abuse treatment facilities should provide onsite, rapid HIV testing rather than referrals to offsite testing—research shows that doing so increases the likelihood that patients will be tested and receive their test results. Treatment providers should also inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drug-abusing populations, and help link them to HIV treatment if they test positive.

Effects of Prescription Drugs on the Brain and Body

PRESCRIPTION DRUGS


Drugs prescribed by a physician can relieve pain and control the symptoms of many disorders and diseases. People who use prescription drugs as directed by a doctor (at the prescribed dose and for the recommended length of time) are at very low risk for addiction or other negative side effects. However, intentional misuse of prescription drugs can be dangerous. Three commonly abused prescription drugs are opioids, central nervous system (CNS) depressants, and CNS stimulants.

Opioids

Opioids, such as morphine, codeine, oxycodone (Oxycontin), and hydrocodone (Vicodin), are prescribed for pain relief. Used correctly, opioids are helpful for people suffering from chronic pain or pain from surgery. These drugs act by attaching to opioid receptors in the brain and spinal cord, and blocking the transmission of pain messages to the brain. Opioids also cause initial feelings of pleasure by acting on the reward system in the brain. Side effects of opioids include drowsiness and constipation.

The Internet makes prescription drugs more easily accessible for abuse. E-mail inboxes are often full of spam e-mails offering the sale of prescription drugs without a prescription. When discussing these drugs with your students, bring up the topic of dangerous and misleading spam e-mails, and how it is important to respect prescription drugs.

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CNS Depressants

CNS depressants include barbiturates and benzodiazepines (e.g., diazepam [ Valium], alprazolam [Xanax], and lorazepam). These medications are prescribed to treat anxiety, tension, and sleep disorders. They slow brain function by increasing the activity of the neurotransmitter GABA. GABA decreases brain activity and causes feelings of drowsiness and calmness, which is helpful in people with anxiety or sleep disorders.

CNS Stimulants

CNS stimulants, such as dextroamphetamine (Dexedrine) and methylphenidate (Ritalin), are prescribed for attention-deficit hyperactivity disorder (ADHD), narcolepsy (a sleeping disorder), and depression that has not responded to other treatments. Stimulants copy the activity of the neurotransmitters dopamine and norepinephrine by stimulating their specific receptors. This results in increased alertness, attention, and energy. Stimulants also result in increased feelings of pleasure, higher blood pressure and heart rate, and increased blood glucose levels.

Scientists propose that there is less dopamine transmission in the brains of persons with ADHD when compared to other individuals. Because stimulants correct this shortfall, individuals with ADHD are at low risk for becoming addicted to stimulant medications. Individuals that have not been prescribed Ritalin abuse the drug by swallowing the tablets or by crushing and then snorting them. This causes wakefulness and euphoria. In people who do not need the medication, the increased dopamine transmission caused by ingesting Ritalin can be highly addictive.

CNS Stimulants

Dextroamphetamine and Methylphenidate

Activate dopamine and norepinephrine receptors, which results in increased alertness, attention, and energy. Stimulants also cause higher blood pressure and heart rate.

Prescription Drug

Examples Drug Effects
Opioids Morphine, Codeine, Oxycodone, Hydrocodone Attach to opioid receptors in the brain and body to block transmission of pain messages.
CNS Depressants Barbiturates and Benzodiazepines Slow brain function by increasing the activity of the neurotransmitter GABA, which decreases brain activity and causes feelings of drowsiness and calmness. These drugs also decrease heart rate and blood pressure.

Drugs in the Home

Prescription Drugs in Combination with Other Drugs

In order to be safe and healthy, patients taking prescription drugs must comply with the medication guidelines set by their doctor. It is important to know how much medicine to take, how long to take it, and what else can have an impact on its effects on the body. Possible interactions with other drugs, vitamins, certain activities, or environmental factors such as sun exposure need to be thoroughly understood by the patient for the prescribed medication. Prescription medications should never be shared.

Misusing prescription drugs can have very negative consequences. At large doses, opioids can be fatal because they can cause heart and breathing rates to slow down or stop. High doses of stimulants can cause an irregular heartbeat, seriously high body temperatures, and the potential for heart attacks and death. Taking stimulants in combination with over-the-counter cold medications can cause abnormalities in blood pressure and heart rhythm. Taking opioids and CNS depressants in combination with other drugs, such as alcohol or antihistamines, can cause severe respiratory problems and death.

Prescription Drug Withdrawal

Long-term abuse of prescription drugs may cause addiction and produce withdrawal symptoms if the drug is discontinued. The withdrawal symptoms from prescription drug abuse vary, depending on the particular drug being abused. The withdrawal symptoms that result from opioid abuse include restlessness, insomnia, vomiting, muscle and bone pain, diarrhea, and cold flashes with goose bumps. Withdrawal from CNS depressants may cause the brain’s activity to rebound and race out of control, resulting in seizures and other harmful consequences. The withdrawal symptoms of CNS stimulants include depression, fatigue, insomnia, loss of appetite, and craving for more stimulants.

INHALANTS

Inhalants are a class of chemicals that have many useful purposes in households but were never meant to enter the body. They are intentionally misused by sniffing or inhaling. They can be sprayed directly into the nose or mouth, inhaled from substances dropped into a bag (“bagging”), inhaled from a soaked rag (“huffing”), or inhaled from a balloon. Inhalants enter the bloodstream directly through the lungs and rapidly travel to the brain. Users experience an immediate “head rush” or high.

Many inhalants are commonly found in the home. They can be classified into four categories: volatile solvents, aerosols, gases, and nitrites.

Volatile solvents – Paint thinners and removers, dry-cleaning fluids, degreasers, gasoline, glues, correction fluids, felt-tip marker fluids

Aerosols – Sprays containing propellants and solvents, including spray paints, deodorants and hair sprays, vegetable oil sprays for cooking, fabric protector sprays, whipped cream

Gases – Household gases and medical anesthetics: ether, chloroform, halothane, nitrous oxide (laughing gas)

Nitrates – Cyclohexyl nitrite, isoamyl (amyl) nitrite, isobutyl (butyl) nitrite; sold under the name of “poppers,” or found in certain room deodorizing sprays Inhalant abuse can damage areas of the brain involved in cognitive functions and produce symptoms ranging from mild impairment to dementia. Inhalant abuse can also damage brain areas responsible for movement and vision.

Permanent hearing loss and irreversible damage to nerves throughout the body can occur from using inhalants. Inhalants can cause hepatitis, liver failure, and muscle weakness. They also interfere with the production of red blood cells, which can result in a life-threatening condition known as aplastic anemia. A condition called “sudden sniffing death” may occur when inhaled fumes replace oxygen in the lungs and brain and cause suffocation. Finally, inhalants can interfere with heart rhythm, leading to a heart attack. This can occur from a single session of repeated inhalant use.

Effects of Inhalants on the Brain

Scientists are investigating the exact way in which inhalants slow and stop the activities of neurons. Some inhalants also damage the structure of the brain, particularly the myelin, or insulation, that the axons. Because myelin helps messages travel through the neurons, this damage can be very serious. The parts of the brain most affected by inhalants are the cerebral cortex, cerebellum, hippocampus, and brain stem. Because of the damage to the cerebellum, heavy users of inhalants often show signs of decreased coordination, moving slowly and clumsily.

The frontal cortex of the brain, important for solving problems, and the hippocampus, a part of the brain involved in memory, are also affected by inhalant abuse. Researchers think that inhalants deprive the brain of oxygen. This causes the death of nerve cells and a decrease in nerve cell activity. Thinking, memory, and the ability to learn are all negatively affected.

Many inhalants activate the brain’s reward system and stimulate the release of dopamine. This is thought to be responsible for the pleasurable feelings associated with inhalant use.

Long-Term Inhalant Abuse

People who use inhalants over a long period of time feel a strong urge to continue using them. Effects of long-term abuse include weight loss, muscle weakness, disorientation, inattentiveness, lack of coordination, irritability, and depression.