Medical Detoxification (Pre-Treatment)

Detoxification is a first step in the process of getting treatment. This step lasts for several days and allows the body to rid itself of a large amount of alcohol or other drugs (toxins). The person going through detox feels very sick, and has trouble eating, sleeping, and concentrating. Detoxification requires medical supervision, either at a hospital or inpatient or outpatient treatment facility. It is most effective when it is followed by referral to additional drug treatment. Detoxification does not address any psychological, social or behavioral problems that accompany addiction. Further behavioral modification and therapy are needed to achieve successful recovery and long-term abstinence. Research has shown that detoxification alone is not effective.

If a person with an addiction detoxes on their own by just stopping their drinking or drug use, the process can be medically dangerous and even fatal, particularly with alcohol or Valium.

Detoxification may be the best option if the person cannot stop drinking or using drugs even for a few days, shows signs of withdrawal (for example, shaking, sweating, irritability, agitation), or has medical problems that would need monitoring when all substance use had stopped.

Inpatient, Outpatient, and Partial Hospitalization Treatment

Inpatient and outpatient treatment are more similar than they are different. Inpatient requires staying overnight for a period of time at a treatment facility. Outpatient treatment happens at a hospital or a treatment facility, but the person stays at home and attends the program during the day. According to Dr. Mary Ann Amodeo, Director, Alcohol and Drug Institute for Policy, Training and Research; Associate Professor of Clinical Practice, 85% of people in treatment receive outpatient treatment.

But both usually include individual and group therapy, couples or family therapy, education about the nature of addiction, medications when indicated, and 12-step programs. Staff members generally include a combination of certified alcohol and drug counselors, social workers, psychologists, psychiatrists, psychiatric nurses, and others trained to treat addiction problems.

Outpatient treatment differs in the type and intensity of services offered, but typically require people to visit a clinic at regular intervals to participate in programs that may include individual or group counseling, drug education and relapse prevention. Most outpatient treatment programs provide about 2-6 hours per week of care. Outpatient treatment may be the best option if:

• the person wants or needs to continue going to work everyday, since there is no job interruption with outpatient treatment.
• the person does not have the means to pay for inpatient treatment, because outpatient treatment is considerably less expensive.
• the person is unwilling to be away from the family.
• the situation at home will involve support and assistance for attending the program and will be free of exposure to drinking and drug use.

People in outpatient treatment need to be prepared to face the "real world" during each day of treatment. Although people in treatment still face challenges, the day-to-day "tests" of their recovery may actually strengthen their resolve and coping methods.

A partial hospitalization program is a more intense form of outpatient treatment. People live at home and attend treatment during the day for 3-12 hours per day for 3-7 days a week. Partial hospitalization programs may make sense if your family member needs an intensive and structured treatment experience that is less expensive than inpatient care. Partial hospitalization may also be a good choice if the situation at home will involve support and assistance for attending the program and will be free of exposure to drinking and drug use.

For inpatient programs — also known as short-term residential programs or chemical dependency units -- people stay at a treatment facility for an extended period of time, usually three to six weeks. This is often followed by extended outpatient therapy or participation in a Twelve Step or other self-help group. The first phase of recovery can be intense, so being away from home gives people the time and space they need to start their recovery. Inpatient treatment may make the most sense if:

• the person has already tried outpatient treatment and it didn't seem to work.
• the person has medical problems such as heart problems, liver problems, digestive problems, infections, intense depression, or anxiety that require more than the usual attention.
• the home or social situation is so chaotic that day-to-day support is needed.
• the person lives so far away from an outpatient treatment program that regular attendance isn't possible.

Inpatient care has its drawbacks. People who go far from their communities to receive treatment will have to work harder to connect to aftercare services and self-help group support once they return home. The treatment program should help them make those connections before they leave.

Long-Term Residential Treatment

Residential Treatment provides 24-hour care in non-hospital settings to patients with relatively long histories of drug dependence, involvement in serious criminal activities and/or seriously impaired social functioning. The best-known residential treatment model is the therapeutic community (TC), but residential treatment may also employ other models.

Therapeutic communities are highly structured residential programs with planned lengths of stay ranging from six to 12 months, or more. They focus on re-socializing people to a drug-free, crime-free lifestyle by using the program's other residents, staff and the social context as active components of treatment. Programs that serve youth also require patients to attend classes, so they do not fall behind in their education. For adults, job training and other support services may be available.

Methadone (Agonist Maintenance Treatment)

Agonist maintenance treatments, often referred to as methadone maintenance therapy, are designed for those with opiate addictions and are usually conducted in outpatient settings. Patients are given a long-acting synthetic opiate medication, such as methadone, that prevents opiate withdrawal, blocks the effects of illicit opiate us and decreases opiate craving. Methadone is a safe and effective medication for people who are addicted to heroin or other opiate drugs, including prescription painkillers like OxyContin (oxycodone). Treatment is usually conducted in outpatient settings such as a daily visit to a clinic where people are given methadone by mouth in a single standard dose. Medication is often coupled with counseling, therapy and other services.

People who take opiates for a long time experience profound changes in their brain. Methadone reduces the desire for opiates and stabilizes people so they can return to work and family. Any opiate effects are blocked in people who are taking regular doses of methadone, and they do not suffer the medical and behavioral problems other opiate users experience.

Some people mistakenly believe that methadone replaces one drug addiction with another. But as it is used in methadone maintenance treatment, methadone is not a heroin substitute. Its pharmaco¬logical effects are very different from those of heroin.

The minimum length for effective methadone maintenance treatment is twelve months. Some people will continue to benefit from methadone over a period of years. Methadone maintenance treatment might make the most sense if the person has been using heroin or other opiates for some years, has been through detoxification on more than one occasion or has attempted several times to live drug-free and has been unsuccessful, or has other medical problems. People taking methadone must be able to attend a clinic daily to receive methadone and participate in other aspects of the program.

Methadone is not commonly administered to youth and those under the age of 18 must have special permission from the state to participate.

Naltrexone (Narcotic Antagonist Treatment)

Naltrexone is a long-acting synthetic opiate antagonist taken orally (daily or three times a week) that blocks the effects of opiates. It also has no subjective effects or potential for abuse and is not addicting. Patients can hold down jobs and function normally while medicated. Unfortunately, patient noncompliance is a common problem, making the treatment most effective for highly motivated people who desire total abstinence because of external circumstances, including impaired professionals, parolees, probationers and prisoners in work-release status.

Twelve Step and Self-Help Groups

Self-help groups can complement and extend the effects of professional treatment. The most well-known self-help groups are Alcoholics Anony¬mous (A.A.), Narcotics Anonymous (N.A.), and Cocaine Anonymous (C.A.) all of which are based on a Twelve Step model. Smart Recovery is another well-known group.

Anonymity and ongoing abstinence, maintained by working through Twelve Steps to recovery, are two of the hallmarks of all Twelve Step groups. Programs based on A.A. also include accepting certain spiritual values; however, those values are open to interpretation.

Most formal treatment programs, such as in-patient, out-patient and partial-hospitalization, encourage people to participate in self-help groups during and after treatment. They involve no cost, have no waiting lists, and are readily available in most communities — powerful incentives for participation. Most metropolitan areas have meetings in a number of locations and for a variety of populations so people can find a program that's right for them. In fact, experts advise shopping around for the right group by attending at least six meetings in different locations.

Also, meetings are held year round, including holidays like Thanksgiving, Christmas, and New Year's Eve, to provide support to people in recovery and their families who may feel especially vulnerable at these times when other people are drinking as a part of their celebrations.

Research on A.A. has found that participation can be as successful as formal treatment for people who attend meetings weekly or more frequently, participate actively, and attend for over two years. Twelve Step groups combined with and following treatment increase the participant's chances of maintaining abstinence, relationships, and employment.

Trying a twelve-step program by itself may be appropriate if:

• anonymity is a primary concern.
• constrained finances make attending a formal treatment program impossible.
• the person needs sustaining, daily reinforcement to stay sober.
• the person wants a spiritual component to treatment.

Recovery or Sober Houses

Some people leave treatment for a transitional residence where they live with other people in recovery. Residences often have a small number of clients, a small professional staff, clear and enforced rules about abstinence, and a significant level of structure -- somewhere between what is found in inpatient treatment and what is found in a family household. Residents are expected to become employed within several weeks of entry and participate in the upkeep of the residence. Such programs are most often used by those without a stable social support system.

A long-term residential program may make the most sense if the person:

• has been unable to remain alcohol- and drug-free when living alone, at home, or with friends or relatives.
• can make a 3-6 month commitment to live in a group situation where a major focus is remaining clean and sober.
• wants to assume more responsibilities while living in a structured setting.
• is able and willing to accept group support from others in recovery.

Treating Mental Health Problems (Co-Occurring Disorders)

Co-occurring mental health and substance use disorders are not uncommon. Between 30 percent and 60 percent of drug abusers have concurrent mental health diagnoses, while 40 percent to 60 percent of adolescents and young adults in drug or alcohol treatment also need attention for psychiatric problems. Many experts agree that both substance abuse and mental health disorders should be treated in an integrated way. However, serving people with co-occurring disorders is challenging, since substance abuse counselors and mental health providers have different treatment approaches and goals (some of which are in direct conflict). Patients with co-occurring disorders also tend to be more disabled and have higher rates of medical problems, legal troubles and homelessness

Treatment and the Justice System

Treatment for those involved with the criminal justice system may be delivered prior to, during, after or in lieu of incarceration. Since many drug abusers and addicts often come into contact with the justice system before other health or social institutions, judicial intervention can interrupt -- and in some cases shorten -- a career of drug use. In 1999, 47 percent of all first-time treatment admissions and more than half of adolescent marijuana admissions were referred by the criminal justice system. People in treatment under legal coercion can also have more successful outcomes, since they tend to stay in treatment for a longer period time and/or fully complete their programs.

There are many alternatives to incarceration used with offenders who have drug disorders, including limited diversion programs, pretrial release conditional on entry into treatment, and conditional probation with sanctions. Programs mandate and aggressively monitor drug treatment progress and in some cases, offer offenders other services that address their special needs, such as counseling, medical care, parenting instruction, family counseling, school and job training and legal and employment services.

For people already incarcerated, there are a number of treatment options available, including drug education classes, self- help programs and therapeutic community or residential treatment models. For youth, over a third of juvenile correctional facilities (37 percent) provide on-site substance abuse treatment. Over 90 percent provide individual counseling and nearly three-quarters (72 percent) offer family counseling, an important element in treating adolescents for drug abuse.

For best results, experts recommend that people participating in treatment are segregated from the general prison population (so that the "prison culture" does not overwhelm progress toward recovery) and that they continue their treatment through community-based programs once they leave incarceration. Successful models have been proven to prevent drug abuse relapse by more than one- third and to reduce rearrest by 25 to 50 percent among participants.

Are There Additional Treatment Options if the Typical Ones Don't Work?

Some people have found assistance by reaching out to members of their community to find others who have overcome addiction. There is a huge recovery community across the country, and members of this community can share their wisdom about what methods were helpful to them.

Other people find help attending bible-study classes, prayer groups, or taking on responsibilities in their local church or place of worship. Such settings provide drug-free environments and encourage attendees to live by a set of values and ethics that include respecting themselves and others, which is consistent with recovery philosophy. And although it is fairly unusual, people do sometimes give up a pattern of drug dependence on their own.

Is Total Abstinence Necessary?

Most treatment programs in the United States view abstinence as the only path to recovery. Although some people, especially some teens, may be treated for "misuse" and return to moderate, non-problem use, much research supports the need for abstinence as a treatment goal for those who have developed alcoholism or drug dependence. Whether total abstinence is necessary or not is a decision to be made between the individual and the treatment provider.

[Sources: Join Together, Mary Ann Amodeo, Ph.D, Director, Alcohol and Drug Institute for Policy, Training and Research; Associate Professor of Clinical Practice; Treatment Research Institute; Drugstory org/National Youth Anti-Drug Media Campaign; NIDA's Principles of Drug Addiction Treatment: A Research-Based Guide; NIDA InfoFax: Treatment Methods (unless otherwise indicated). For more information, please access these publications online at http://www.drugabuse.gov/drugpages/treatment.html.]

Read about Treatment Approaches Used With Programs

There are several approaches used in treatment today. Here is a list of different types – many of which are used in the programs listed in Types of Treatment.

Relapse Prevention Therapy

In relapse therapy, patients learn to enhance self-control skills by recognizing and correcting problem behavior. Specific techniques include weighing the positive and negative consequences of continued drug use, self-monitoring in order to identify high-risk situations for use and developing methods used for coping with or avoiding those situations.

Motivational Enhancement Therapy

For individuals ambivalent towards treatment, this approach aims to quickly motivate patients into discontinuing drug use. The therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. The first session attempts to elicit self-motivational statements and a plan for change that includes suggested strategies for coping with high-risk situations. In subsequent meetings, the therapist monitors change, reviews cessation strategies being used and continues to encourage commitment to change or sustained abstinence. Patients are sometimes also encouraged to bring a significant other to sessions.

Supportive Expressive Therapy

Designed to help patients feel comfortable in relating their personal experiences and to identify/work through their interpersonal relationship issues, it allows participants to explore ways in which to solve these problem feelings and behaviors without falling back on previous addictive behaviors.

Individualized Drug Counseling

Helps patients develop coping skills and other strategies, in order to stop drug use and achieve total abstinence. Twelve-step participation is encouraged, along with other services that address other problem issues, such as employment status, illegal activity and family/social relationships. Counseling sessions are usually scheduled one to two times a week.

Matrix Model

Serving mostly stimulant abusers, the Matrix Model incorporates several treatment methods, including relapse prevention, family and group therapies, drug education and self- help participation. It also offers education for family members affected by the addiction. However, this treatment method relies most heavily on relationships forged between patient and therapist. Acting as a teacher and coach, therapists educate patients about issues critical to addiction and relapse, and attempt to raise the patient's self-esteem, dignity and self- worth through continual encouragement and positive reinforcement of desired behavioral changes. Maintaining a positive relationship is crucial for patient retention.

Behavioral Therapy for Adolescents

Behavioral therapy attempts to help young patients exert control by avoiding situations associated with drug use, recognizing and changing thoughts, feelings or plans that lead to drug use and enlisting family/friends to help them stay away from drugs. Therapeutic activities may include fulfilling specific assignments, rehearsing desired behaviors and recording and reviewing progress. Praises and privileges are consistently given for meeting assigned goals and demonstrating desired behaviors as positive reinforcement.

Multidimensional Family Therapy (MDFT) for Adolescents

Outpatient drug abuse treatment positively utilizes the network of influences on youth behavior by incorporating family as an active part of therapy. During individual and family sessions, therapists he lp develop crucial skills that enable teenagers to cope with life stressors and allow parents to improve their parenting. Young patients attempt to better their decision- making, negotiation, problem-solving and communication skills, while parents work to positively influence their children.

For more information, see What Happens in Rehab?

[Source: National Institute on Drug Abuse]

• Initial Evaluation
• Abstinence
• Learning about addiction
• Group counseling
• AA or other Twelve Step participation
• Individual counseling
• A family program

What will "Rehab" accomplish?

• Abstinence
  In many cases it seems that as long as the substance is in the blood stream, thinking remains distorted. Often during the first days or weeks of total abstinence, we see a gradual clearing of thinking processes. This is a complex psychological and biological phenomenon, and is one of the elements that inpatient programs are able to provide by making sure the patient is fully detoxified and remains abstinent during his or her stay.
• Removal of Denial
  In some cases, when someone other than the patient, such as a parent, employer, or other authority, is convinced there is a problem, but the addict is not yet sure, voluntary attendance at a rehab program will provide enough clarification to remove this basic denial. Even those who are convinced they have a problem with substances usually don't admit to themselves or others the full extent of the addiction. Rehab uses group process to identify and help the individual to let go of these expectable forms of denial.
• Removal of Isolation
  As addictions progress, relationships deteriorate in quality. However, the bonds between fellow recovering people are widely recognized as one of the few forces powerful enough to keep recovery on track. The rehab experience, whether it is inpatient or outpatient involves in-depth sharing in a group setting. This kind of sharing creates strong interpersonal bonds among group members. These bonds help to form a support system that will be powerful enough to sustain the individual during the first months of abstinence.
• "Basic Training"
  Basic training is a good way to think of the experience of rehab. Soldiers need a rapid course to give them the basic knowledge and skills they will need to fight in a war. Some kinds of learning need to be practiced so well that you can do them without thinking. In addition to the learning, trainees become physically fit, and perhaps most important, form emotional bonds that help keep up morale when the going is hard.

For more information, see Treatment Approaches Used Within Programs.

[Source: Written by Jeffery S. Smith M.D. of Addiction Resource Guide. Used with permission.]