Introduction
Various studies have indicated that long-term treatment of addiction is more effective that short-term treatment, which often results in poor outcomes and increased incidence of resumed use on the part of the patient.

Generally, group therapy approach is more effective that individual counselling sessions.  There are cultural differences that make exceptions to this general statement.

Specific treatment programs should be targeted to specific substances of abuse (i.e. one treatment program for persons who abuse alcohol and another for abusers of heroin, and so forth).  Typically, treatments for alcoholism achieve better long-term effectiveness that cocaine, which is better than heroin.

Additionally, programs that are targeted to specific populations (based upon race, culture, profession) are often more effective that "generic" treatment programs.

That treatment can be effective is no longer debated, since studies indicate that drug abuse treatment in prisoners results in substantially reduced numbers of repeat offenders among those that underwent treatment (60-80% of prisoners released are incarcerated at a later date -- only 20% of those receiving treatment return to prison).

Before a person may successively receive treatment, they have to acknowledge the existence of the problem.  This often will not occur until the individual has "hit bottom" or experienced some life-changing occasion (such as severe health problems, loss of spouse of loved one due to the addiction, loss of job, or loss of financial security).  Typically, the earlier the individual recognises the problem, the better the treatment outcome, both for the patient and their family, friends, and/or associates.

One of the first barriers that must be overcome by those treating the patient (or loved ones confronting the patient) is denial.  This is also one of the most difficult barrier to overcome, because often the patient refuses to acknowledge the problem until they do "hit bottom".  In some instances, friends or loved ones may break through the denial barrier and convince the patient of the need for treatment.  Other ways that this barrier may be broken include the following:

Legal intervention -- the treat of loss of property or person freedom, through court of police action, may convince some individuals of the problem

Workplace intervention -- poor performance and threat of job security may serve the same function

Physical or mental health intervention -- deterioration of personal health may warn the patient of the problem

Financial intervention -- loss of income or monies needed to support self or family may also alert the patient of the need for treatment
 

In some cases the denial may be broken by intervention from an "intervention team" -- composed of persons who are concerned for the welfare of the patient.  This team may be composed of one or more the following (and their particular contribution to the team):
Family member -- To express love, understanding, and concern for the individual.  (NOTE that any intervention should be based on this understanding -- confrontational intervention is usually less effective except in extreme cases -- this approach will be discussed later)

Close friends -- To verify the statements of the family member

Co-workers -- Again, to verify the concern of the previous two members and to underscore any work-related problems the addiction may be causing

Recovering addict -- To provide an "I have been there" point of view for the patient -- this member may be one of the above individuals

Counsellor/Facilitator -- The team leader, who may provide the guidance needed to run the intervention and prospective treatment.  This person may a licenced counsellor, psychologist, psychiatrist, or even a clergy member.  If the counsellor/facilitator is not a member of the clergy, then a spiritual advisor appropriate for the individual's culture may also be a member of the team

The goal of the intervention team is obviously to provide a drug-free life for the patient (abstinence with an altered life style).  However, this ultimate goal must be approached by accomplishing specific primary and secondary goals.  Primarily, the patient should be motivated toward abstinence, a drug-free lifestyle, and freedom from the addiction.  These may be accomplished by medical treatment (detoxification), counselling, and support from family and friends.  Secondary goals include an enrichment of career or job, improving the mental and physical health of the patient, and, if appropriate, improved spiritual life.  These are accomplished by the commitment of family, friends, employers, counsellors, and medical and mental health professionals.  Both the intervention team and the patient need to realise that the ultimate goal may never be fully realised (or the common view that treatment never ends -- it is a life-long process that may take years of support and counselling).

The team should plan the intervention ahead of time and have anticipated defences and outcomes prepared for any foreseeable obstacle the patient may present.  Typically, timing, location, and surprise are important features of the intervention.  The team should have prepared a specific treatment plan in mind, should the intervention be successful.  Additionally, the team should follow up the initial intervention (whether or not it was successful), to provide additional intervention strategies or support to the patient.

There are several treatment options available for each patient.  Each may be specific for the severity of the addiction, the stage of treatment, or the needs of the individual.  Some of the specific treatment models are described below:
Hospital detoxification programs -- these are inpatient facilities that provide medical-mediated detoxification and withdrawal from the substance(s).  These are relatively short term.

Social detoxification program -- these may be inpatient or outpatient programs that provide a safe environment for detox/withdrawal.  The main difference between this and the hospital program is that no medical intervention is made (no drugs administered) with the social program.  This model also provides relatively short-term treatment.

Partial hospitilisation and day hospitals are a hybrid of the two approaches described above.  They provide limit medical intervention, counselling, and education.
 

Once the person is no longer physically addicted to the drug, the treatment enters a second stage that is designed to keep the individual drug-free.  A major component of this stage includes counselling, support, and education on the dangers of addiction and relapse.  Treatment options that encompass this phase include the following:
Therapeutic communities -- These are generally long-term residential programs that provide rehabilitative and social services.  These programs typically limit outside contact, which could be detrimental to the treatment program.

Halfway Houses -- permit the patient to retain jobs and outside contacts while providing rehabilitation, support, and counselling.

Sober-living or transitional living programs -- Again, these are a hybrid of the above two approaches.  These are similar to the above programs, but often involve apartment blocks or co-ops for recovering addicts with strong house rules.
 

A third (and controversial) treatment program are harm reduction programs such as methadone clinics.  These have been addressed in the section on opiates.

In addition to supportive medical therapy (i.e. drugs to treat seizures associated with withdrawal, fluids, pain medications) to preserve health, numerous drugs may also be used to lessen the effects of withdrawal during detoxification.
Clonidine (Catapres®) -- lessens withdrawal from opioids, alcohol, and nicotine
Naltrexone (Revia®) and Naloxone (Narcan®) -- reverse the effects of opioids
Flumazenil (Romazicon®) -- reverses the effects of benzodiazepines
Other drugs used in withdrawal programs include antipsychotics and antidepressants to lessen the effects of stimulant (cocaine and amphetamine) addiction.
Some drugs are used to wean patients off of the abused substance slowly.  These drugs will act as a mild form of the abused substance, preventing withdrawal symptoms but not producing the high or rush normally associated with the drug.  These include:
Methadone and l-alpha acetyl methadol -- for the opiates.
Nicotine patches, gum, spray -- for tobacco
Chlordiazepoxide (Librium®) -- for alcohol
Once the patient has been successfully withdrawn from the drug and is no longer physically dependent, some treatment programs will administer other drugs to prevent relapse.  Some of these drugs are designed to reduce the craving associated with abstinence while others, prevent the rush associated with the abused substance if a relapse occurs.  Still others may cause an adverse effect if the patient relapses.  These drugs include:
Bromocriptine (Parlodel®), amantidine (Symmetrel®), and L-Dopa (Larodopa®) -- these agents act as dopamine agonists to stimulate the reward/pleasure centre of the brain without the addictive properties of substances of abuse.  They are used primarily to treat the craving associated with cocaine.

Clonidine (Catapres®) -- used to block the rush of cocaine and other stimulants including nicotine

Naltrexone (Revia®) -- used to block the rush of opiates

Naltrexone (Revia®) and ritanserine -- used to decrease alcohol cravings.

Disulfiram (Antabuse®) -- produces a series of unpleasant side effects if alcohol is ingested while taking the drug, or up to 2 months after taking the drug

Concerns and potential problems that may be encountered treatment/withdrawal/abstinence that are specific for drug classes include the following:
Stimulants (Cocaine and amphetamines) -- Psychiatric problems including paranoia, schizophrenia, depression which may have to be treated with appropriate psychotherapeutic drugs.  Also, the patient may experience prolonged craving, anergia (no energy), anhedonia (no pleasure), and euthymia (a good feeling 3 to 5 days after withdrawal), all of which may complicate treatment.

Tobacco -- Patients may experience anxiety, depression, and craving.

Opioids -- Withdrawal may cause severe pain, which may have to be treated.

Sedative Hypnotics (Barbiturates and benzodiazepines) -- Initial abstinence may cause altered taste perceptions, visual disturbances, anxiety, and may experience a renewal of withdrawal symptoms months after physical withdrawal.  All of the effects may impede treatment.

Psychedelics -- A unique aspect of treating persons who abuse psychedelic substances is the occurrence of "bad trips".  The approach and treatment of a bad trip is best managed by utilising a 5 step process:

1) gain the patients acceptance, trust and confidence

2) reduce any confounding stimuli -- quietly get the patient to a non-threatening environment with a minimum of sensory stimuli

3) reassure the patient -- let them know that they are just experiencing a bad trip, that they will be alright, and that they are in no danger

4) make the patient as comfortable and stress free as possible, get them to rest

5) talk the patient down, using peaceful, non-threatening approaches and avoiding any subject that may be upsetting to the patient.

Additionally, if there are life-threatening complications, medical assistance should be sought.

Once withdrawal has been achieved and health restored to the patient, the next goals in therapy are to provide a drug-free life.  This may be accomplished by several approaches that generally must be combined to contribute to their successful therapy, including alternative activities, counselling and therapy, and non-drug reward incentives.

One of the harder aspects of maintaining a drug-free life is the temptation to use the drug again, often as a result of cues or triggers that the patient may associate with substance abuse.  One approach to lessen the impact that these cues or triggers is to avoid the cues.  Using smoking as an example, the following situations illustrate this approach --

Avoidance -- do not go to bars where smoking is common

Substitution -- rather that smoking after a meal, take a walk after a meal, especially is the substitution can offer a natural reward or natural "high"

Desensitisation -- This controversial approach repeatedly exposes the patient to the cue or environmental trigger (under supervision of a therapist of friend that can prevent the patient's relapse) until the trigger is no longer associated with the drug.

Successful treatment is generally gaged by the following criteria:
Continuous sobriety
Retention in treatment
Completion of specific phases of the treatment plan
Improved family functioning
Positive social and environmental adjustments
Improved vocational, job, and educational functioning
Decreased criminal activity or legal problems

Individual Therapy -- As stated previously, group therapy seems to be more effective in providing support and shared experiences.  However, in some cases individual therapy may be more beneficial.  Advantages of individual therapy include its highly personalised structure, one-on-one encounters, and more intense personal evaluation.  Additionally, some drugs (heroin, sedatives) seem to respond to individual therapy better that group therapy.

Group Therapy -- The advantages of group therapy include support from fellow patients who may provide insight and personal experiences on the recovery process.  There are three major types of group therapy.

Facilitated Groups -- These are typically small and are usually run by the therapist.

Peer Groups -- These are usually larger, with the therapist playing a minimal role in the session.

12-Step Groups -- These are the most widely used groups in addiction treatment.  They have no professional therapist involvement and rely solely on patient involvement.  12 Step groups exist for many addictions including the classic Alcoholics Anonymous, Narcotics Anonymous, Marijuana, Gamblers, Overeaters, Sexaholics, Emotions, Relationships, and Shoppers Anonymous.  Additionally, 12 step support groups for families have been formed (Al-Anon for spouses, ACoA for children of patients, and Alateen for teen alcohol abusers).  These programs are free, which is beneficial for many poor patients.  The program is designed to break the addiction, supports the view that it is a lifelong struggle, promotes open-mindedness, supports lifelong abstinence, and possesses a strong spiritual component.  It also contains components of accountability, reparations, and continuous support from fellow members of the group.  Other, secular bases groups that are similar in nature have been formed including Rational Recovery, Secular Organisation for Sobriety, Women for Sobriety, and Men for Sobriety.

Other group approaches to therapy include educational groups (which include homework lessons and whose primary goal is to education the recovering addict) and specifically targeted groups (usually based upon social subpopulations, topics, or professions).

Family dynamics can play a major role in the success or failure of any treatment program.
Family Systems Approach -- This model of family involvement examines how a functional family copes with both external and internal changes in its environment.  Included in the strategies are daily routines, family traditions, and short-term problem-solving strategies.

Family Behavioural Approach -- This model supports the view that many family behaviours are learned and that the behaviours must change once treatment has been started.  Supports positive reinforcement for both the patient and the family unit.

Family Functioning Approach -- Distinguished between different family types and how each may be different in a particular patient's treatment.

Functional family system -- Emotionally healthy families that provide support

Neurotic or enmeshed family system -- the "dysfunctional" family, that may often impede successful therapy

Disintegrated family system -- generally treats the family and the patient separately, with the common goal of restoring functionality.  This system may also include single-parent families.

Absent family system -- no family is available for support

Social Network Approach -- Uses support groups and friends to assist both the patient and their family

Tough Love Approach -- This controversial approach is most often used for recalcitrant patients who do not acknowledge the attempted assistance by the family and continue their denial.  It involves separation of the patient from their family (which must learn to cope with the absence of the patient) until an appropriate time in treatment, when contact may be re-established.

Dynamics of Family Interaction
Co-Dependency -- Co-dependents are family members who are dependent upon the addict AND their addiction to function normally (for instance a spouse who uses the addiction to gain power over the family or a son who has become the "head of the family" due to his father's addiction).  Co-dependency often perpetuates the addiction (usually unconsciously) and the family member must realise their role in the addiction before successful treatment may ensue.

Enabling -- The family behaviour also perpetuates the addiction, but by a means that allows the addict to continue in their behaviour.  For example, paying off drug debts, continuing support for the addict without requiring a change in their behaviour, avoiding confrontation concerning the addiction.

Dynamics of Children

Model Child -- high achievers and highly responsible -- often become enablers for the patient

Problem Child -- emotional problems, often the source or excuse for continued addiction, may also become addicts themselves

Lost Child -- withdraw into themselves, to avoid the problems caused by parental addiction

Mascot Child -- trivialises the problem, minimises serious issues, and superficial in their family relationships.  Outwardly they may be the family clown, but are often inwardly more of the lost child.

Adult children of alcoholics often display emotional immaturity or problems with relationships and often exhibit low self-esteem.  A 12 step support group for these persons is ACoA.

Youth -- young people often have a perception of immortality and exhibit much greater degrees of denial that adults, making treatment more difficult.  They are more responsive to peers than to adults and treatment usually includes peer involvement.  They are also very reward-oriented and expect instant gratification.  Therefore, their treatment often includes frequent positive reinforcement for successful stages of therapy.

Elderly -- There are very few treatment programs specifically targeted for older patients.  The lack of family support is often a problem with these patients (spouses may have died or children live away from the patient -- isolating them from family support).

Ethnic Groups -- As stated previously, cultural difference may play a major role in the treatment process.

African American -- Traditionally, African Americans have developed a higher emotional pain threshold and are therefore more resistant to attempts at treatment.  Drug use and traffic may serve as a direct or indirect economic resource, and in urban areas, the environment may be more conducive to their use.  As a culture, they have a strong sense of personal boundaries, which may also impede treatment.  Additionally, perceptions of conspiracy and persecution often delays treatment (especially if it arises from sources outside their culture).  Spiritual involvement and aspects are often effective in the treatment process of African Americans.

Hispanic American -- Commonalities within Hispanic populations (language, religion, strong family structure) all contribute to the successful treatment of this subpopulation.  Again, spirituality may play a significant role in successful treatment.

Asian American -- Commonalities among Asian Americans include a strong sense of family, high respect for education, less emotional display, and reluctance to discuss health and social problems.  Typically, Asian Americans will respond to individual or professional therapy than to peer group therapy.  Attempts to "save face" or protect the family reputation often delay the initiation of therapy.

Native American -- Cultural and regional differences play a major role in the successful treatment of Native Americans.  Education and locale are also important factors for the initiation and continued success of treatment.
 

Other Groups -- As stated previously, other subpopulations (handicapped, homosexual, homeless) may also benefit from treatment that is targets specifically for their population.

Development Arrest -- As described in previous sections, many addicts may have an arrested state of emotional development and maturity.  This may impede treatment.

Follow-Through -- Failure of health-care providers, therapists, family members, friends, and co-workers to maintain support and follow-up may result in relapse.  As stated previously, in many cases, therapy is a continuous process by all persons involved in the treatment program.

Conflicting Goals -- Often the goals of treatment may be different.  While a family may truly desire successful treatment, the patient may merely participate to avoid prosecution or to satisfy their family or employer, with no real desire to successfully participate in the therapy.  (RECALL that the patient has to truely want to quit their addiction for treatment to be successful.)  Additionally, the goals of the treatment program (to improve the health and maintain a drug-free life for the patient) may be at conflict with the goals of society (to reduce crime or health care costs).

Treatment Resources -- As with any other program, the lack of funds or adequate number of treatment centres may prevent successful treatment of all persons wishing to seek recovery.

END COURSE MATERIAL