Fact Sheet Series > Substance Abuse Treatment

Substance Abuse Treatment for Injection Drug Users: A Strategy with Many Benefits
February 2002

This fact sheet series

These six fact sheets address substance abuse treatment - one of the most important ways to help injection and other drug users stop using drugs and reduce their risks of blood-borne diseases such as HIV and hepatitis B and C. By helping individual IDUs, substance abuse treatment also can have a profound and positive effect on families and communities. This fact sheet introduces the topic and explains its importance. The other fact sheets are:

• What Can We Expect from Substance Abuse Treatment?

• Linking HIV Prevention Services and Substance Abuse Treatment Programs

• Methadone Maintenance Treatment

• Policy Issues and Challenges in Substance Abuse Treatment

• Substance Abuse Treatment and Public Health: Working Together to Benefit Injection Drug Users

See the end of this fact sheet for information on how to get this series and other materials on preventing HIV and other blood-borne infections among injection drug users (IDUs).

Substance Abuse Treatment Is a Life-Saver for Many IDUs

No matter how or why an individual starts using drugs, over time, repeated drug use causes significant, long lasting changes in brain structure and function that lead to addiction. Today, addiction is defined as compulsive drug seeking and using, even in the face of terrible personal and social consequences. It's a chronic, complex brain disease. For many IDUs, addiction takes over their lives, destroying their ability to function in family, workplace, and community.

Addiction has powerful biological and behavioral dimensions. As a result, most IDUs cannot quit on their own. Substance abuse treatment can help because it offers the medical, psychological, and behavioral support that individuals need to stop using drugs.

Substance Abuse Treatment Is a Powerful Disease Prevention Strategy

Some IDUs become addicted through smoking or snorting and only begin injecting after their addiction is well underway. Early substance abuse treatment may be able to prevent some users from beginning to inject. For those who already inject, treatment can help them reduce or stop injecting. In either case, substance abuse treatment can reduce the chances of blood-borne HIV and hepatitis B and C transmission. Injection drug use is a major force driving the HIV epidemic. It's also responsible for 60% of hepatitis C cases:

• IDUs who do not enter treatment are up to six times more likely to become infected with HIV than are IDUs who enter and remain in treatment.

• Between 50%-80% of IDUs become infected with hepatitis C within 6-12 months of starting to inject drugs.

In addition, high-risk drug practices and high-risk sexual behaviors (such as not using condoms) are often linked because drugs can make users feel less inhibited. Some users also trade sex for drugs or money to buy drugs. By reducing drug use, substance abuse treatment can also help reduce high-risk sexual behaviors.

Finally, treatment is a good setting for reaching IDUs and their partners with HIV prevention and care messages and interventions. It also can be a bridge to other needed services, such as primary health care, mental health, or other social services.

More Reasons to Support Substance Abuse Treatment

Starting methadone maintenance treatment (MMT) reduces the mortality rate for opiate addicts to less than one-third of what it would have been before they entered treatment. Substance abuse treatment's effectiveness, particularly methadone maintenance treatment, has been repeatedly demonstrated. By helping a person reduce or stop using drugs, it can have a positive impact on many facets of IDUs' lives. This includes improving their health, their ability to get and hold a job, their family stability, as well as reducing their involvement with crime. Substance abuse treatment is as effective as treatment for other chronic diseases, such as asthma, diabetes, and hypertension.

Treatment is a high-return social investment that makes financial sense for communities and the nation. Every $1 invested in treatment reduces the costs of drug-related crime, criminal justice costs, and theft by $4 to $7. The average cost of 1 year of methadone maintenance treatment is $4,700. The cost of 1 year of incarceration per person is about $18,700. When health care savings are added in, total savings can exceed costs by a ratio of 12 to 1.

Substance Abuse Treatment Comes in a Variety of Forms

Detoxification: "Detox" programs wean drug users from their immediate physical dependence on drugs. Individuals should be under close medical supervision during this process. Detox is not a treatment program per se, but rather is an essential first step to treatment. Detox without long-term treatment often leads to relapse to drug use.

Residential treatment: This approach can involve either short-term intensive treatment or a longer-term program. Long-term treatment models use a variety of therapeutic approaches. Residential treatment programs usually include self-help group meetings.

Therapeutic communities (TC): Patients¹ generally spend 6-18 months in these highly structured, peer-based residential treatment programs. They are designed to help patients alter, modify, and re-learn behaviors through intensive educational, medical, legal, social, and psychological counseling services. TCs have been successfully adapted to meet the needs of adolescents, women, those with severe mental health problems, and prisoners in the criminal justice system.

Outpatient treatment: These programs serve about half of all those in treatment. It is the least restrictive form of treatment and often works well for people who are employed and who have stable social and family environments. Services include drug education, group counseling, intensive day treatment, and self-help or 12-step groups.

Medication-assisted treatment: In this treatment approach, patients receive medication to block the effects of opiates. Methadone maintenance treatment is the most common medication-assisted treatment program. Levo-alpha acetylmethadol (LAAM) and naltrexone are also used in this approach, though less frequently. Another alternative, buprenorphine, is expected to become available in 2002. A medication-assisted approach is most effective when combined with counseling and other behavioral interventions.

Complementary counseling/education/support strategies: Psychosocial treatments, including self-help groups, as well as professionally led groups focusing on cognitive behavioral therapy, vocational rehabilitation, and other strategies, are not formal substance abuse treatment. However, they provide essential emotional and personal support and opportunities to develop skills that help individuals in their day-to-day recovery efforts.

12-step programs: These programs, including Narcotics Anonymous (NA) and Cocaine Anonymous (CA), are built on the Alcoholics Anonymous (AA) model. This approach provides an opportunity for men and women to share the experience, strength, and hope gained from their efforts to recover from addiction. The clear goal is abstinence; any use of drugs or alcohol is viewed as unacceptable.

Efforts to Provide Substance Abuse Treatment Face Many Challenges

Coverage

It's estimated that in any given year, 3 million people in the U.S. receive alcohol or substance abuse treatment. However, 13-16 million people could benefit from such treatment. These 13-16 million are highly diverse in their demographics, risk behaviors, and economic and social circumstances. As a result, a variety of programs and interventions are needed to provide therapy that people will accept and that will meet their needs. However, there aren't enough providers. Limited public funds and reductions in coverage by managed care plans further restrict the ability of supply to meet demand.

Access

Individuals seeking treatment for their injection and other drug use face a number of barriers to obtaining it. They may not know about available treatment programs and the services provided. Substance abuse treatment facilities may not be conveniently located or be open at times that work for IDUs. Other barriers, such as fees to pay, forms to fill out, a need for a referral, or waiting lists, further limit an IDU's ability to obtain substance abuse treatment services. These barriers to access, combined with the stigma and negative reactions often faced by IDUs, can create powerful feelings of mistrust and alienation and a strong reluctance to seek out or participate in programs or services.

Quality

Programs face a host of challenges in providing high-quality care. Funding limitations and reimbursement restrictions hamper the provision of necessary services. Other issues relating to quality include:

• Keeping IDUs in treatment for a long enough time to be effective (for example, research has shown that residential or outpatient treatment for fewer than 90 days is of limited or no effectiveness; methadone maintenance patients should have at least 12 months of treatment).

• Ensuring that providers have appropriate and sufficient training and expertise.

• Providing services and treatments in sufficient and appropriate quantities (for example, while medication should be individualized, research indicates that most people will benefit from methadone doses of 60-120 mg/day rather than 30 mg/day).

• Ensuring that participating IDUs receive needed primary care and psychosocial services that meet their health problems and social services needs and complement their substance abuse treatment.

Negative attitudes and stigma

Many negative myths, stereotypes, and attitudes are widely believed about drug users and their lives, the health and safety risks they take, and their ability to overcome addiction. These beliefs have profoundly affected the environment in which substance abuse treatment services are provided and extend to the professionals who provide these services. Policies that result in substantial investment in prisons and criminal justice institutions, laws and regulations limiting efforts to provide IDUs with access to sterile syringes, and community resistance to substance abuse facilities and programs ("not in my back yard") all reflect these attitudes and biases.

New Efforts to Improve and Expand Substance Abuse Treatment

Despite these challenges, a number of recent initiatives on national and state levels are attempting to forge a new environment in which substance abuse is recognized as a public health problem and a treatable disease, and in which high-quality treatment services and programs are widely available. Among the most notable are:

• Several states have radically changed the way they deal with individuals charged with violations of drug laws. For example, in November 2000, California voters resoundingly passed Proposition 36, a new measure to require substance abuse treatment, not incarceration, for individuals convicted of "non-violent drug possession." The state estimates it will save between $100-150 million per year and counties a further $40 million per year because of smaller prison and jail populations. This vote demonstrated widespread support for the public value of treatment versus incarceration. For more information, visit: Legislative Analyst's Office: Analysis of the 2001-02 Budget Bill.

• On May 17, 2001, new federal regulations were issued to replace the program under which methadone and other medications used to treat opiate addictions had been regulated and administered for the previous 30 years. The regulations create a new accreditation program managed by the federal Center for Substance Abuse Treatment (CSAT) that will improve the quality of care through a greater emphasis on individualized treatment planning, increased medical supervision, and assessment of patient outcomes.

To Learn More About This Topic

Visit websites for these materials:

• Preventing Blood-borne Infections Among Injection Drug Users: A Comprehensive Approach, which provides extensive information on HIV and viral hepatitis infection in IDUs and the legal, social, and policy environment, and describes strategies and principles of a comprehensive approach to addressing these issues.

• Interventions to Increase IDUs' Access to Sterile Syringes, a series of six fact sheets.

• Drug Use, HIV, and the Criminal Justice System, a series of eight fact sheets.

Visit these websites for information and materials on substance abuse treatment and HIV prevention:

• The Substance Abuse and Mental Health Services Administration's (SAMHSA) National Clearinghouse for Alcohol and Drug Information (NCADI).

• SAMHSA's Center for Substance Abuse Treatment (CSAT).

• National Institute on Drug Abuse.

• Office of Justice Programs, U.S. Department of Justice.

• SAMHSA's Office of Applied Studies (OAS), which provides data on drug and alcohol abuse, the nation's drug abuse treatment system, and drug-related emergency department episodes through the Drug Abuse Warning Network (DAWN) data collection system.

• White House Office of National Drug Control Policy (ONDCP).

• Join Together, a community coalition that supports community-based efforts to reduce, prevent, and treat substance abuse.

Check out these sources of information:

Abdul-Quader AS, Friedman SR, Des Jarlais DC, et al. Methadone maintenance and behaviors in intravenous drugs users that can transmit HIV. Contemporary Drug Problems 1987;14:425-433.

Ball JC, Ross A. The effectiveness of methadone maintenance treatment. New York: Springer-Verlag; 1991.

Bellin E, Wesson J, Tomasino V, et al. High dose methadone reduced criminal recidivism in opiate addicts. Addiction Research 1999;7(1):19-29.

Gerstein DR, Harwood HJ, editors. Treating drug problems. Vol. I: A study of the evolution, effectiveness, and financing of public and private drug treatment systems. Washington (DC): National Academy Press; 1990.

Hubbard RL, Marsden ME, Rachal JV, et al. Drug abuse treatment: a national study of effectiveness. Chapel Hill (NC): University of North Carolina Press; 1989.

Jones TS, Anderson T. "Junkiephobia": a new concept to capture the stigma and ostracism of drug users and limitations on HIV prevention for drug users. Poster presented at the National HIV Prevention Conference, Atlanta (GA), August 29-September 1, 1999.

Joseph H, Stancliff S, Landgrod J. Methadone maintenance treatment (MMT): a review of historical and clinical issues. Mt. Sinai Journal of Medicine 2000;67(5&6):347-364.

Leshner A. Addiction is a brain disease. Issues in Science and Technology. 2001;17(3).

McLellan AT, Woody GE, Metzger D, et al. Evaluating the effectiveness of addiction treatments: reasonable expectations, appropriate comparisons. Milbank Quarterly 1996;74(1):51-85.

National Institutes of Health. Effective medical treatment of opiate addiction. NIH Consensus Statement Online. Bethesda (MD): NIH; 1997, Nov 17-19;15(6):1-38.

National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide. Rockville (MD): NIDA; 1999. NIH Publication No. 99-4180.

Sorensen JL, Copeland AL. Drug abuse treatment as an HIV prevention strategy: a review. Drug and Alcohol Dependence. 2000;59(1):17-31.

¹ Individuals participating in substance abuse treatment are described in various ways, including "clients" and "patients." In this series of fact sheets, we use the term "patients."

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