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Drug Addiction Treatment in the United States
| Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches. |
Drug addiction is a complex disorder that can involve virtually every aspect of an individual's functioning: in the family, at work and school, and in the community.
Because of addiction's complexity and pervasive consequences, drug addiction treatment typically must involve many components. Some of those components focus directly on the individual's drug use; others, like employment training, focus on restoring the addicted individual to productive membership in the family and society (See Diagram "Components of Comprehensive Drug Abuse Treament"), enabling him or her to experience the rewards associated with abstinence.
Treatment for drug abuse and addiction is delivered in many different settings using a variety of behavioral and pharmacological approaches. In the United States, more than 13,000 specialized drug treatment facilities provide counseling, behavioral therapy, medication, case management, and other types of services to persons with substance use disorders.
Along with specialized drug treatment facilities, drug abuse and addiction are treated in physicians' offices and mental health clinics by a variety of providers, including counselors, physicians, psychiatrists, psychologists, nurses, and social workers. Treatment is delivered in outpatient, inpatient, and residential settings. Although specific treatment approaches often are associated with particular treatment settings, a variety of therapeutic interventions or services can be included in any given setting.
Because drug abuse and addiction are major public health problems, a large portion of drug treatment is funded by local, State, and Federal governments. Private and employer-subsidized health plans also may provide coverage for treatment of addiction and its medical consequences. Unfortunately, managed care has resulted in shorter average stays, while a historical lack of or insufficient coverage for substance abuse treatment has curtailed the number of operational programs. The recent passage of parity for insurance coverage of mental health and substance abuse problems will hopefully improve this state of affairs.
General Categories of Treatment Programs
Research studies on addiction treatment typically have classified programs into several general types or modalities. Treatment approaches and individual programs continue to evolve and diversify, and many programs today do not fit neatly into traditional drug addiction treatment classifications. Examples of specific research-based treatment components are described in General Categories of Treatment Programs.
Detoxification and Medically Managed Withdrawal
Detoxification is the process by which the body clears itself of drugs and is often accompanied by unpleasant and sometimes even fatal side effects caused by withdrawal. As stated previously, detoxification alone does not address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery. The process of detoxification often is managed with medications that are administered by a physician in an inpatient or outpatient setting; therefore, it is referred to as "medically managed withdrawal." Detoxification is generally considered a precursor to or a first stage of treatment because it is designed to manage the acute and potentially dangerous physiological effects of stopping drug use. Medications are available to assist in the withdrawal from opioids, benzodiazepines, alcohol, nicotine, barbiturates, and other sedatives. Detoxification should be followed by a formal assessment and referral to subsequent drug addiction treatment.
Further Reading:
Kleber, H.D. Outpatient detoxification from opiates. Primary Psychiatry 1:42-52, 1996.
Long-Term Residential Treatment
Long-term residential treatment provides care 24 hours a day, generally in nonhospital settings. The best-known residential treatment model is the therapeutic community (TC), with planned lengths of stay between 6 and 12 months. TCs focus on the "resocialization" of the individual and use the program's entire community—including other residents, staff, and the social context—as active components of treatment. Addiction is viewed in the context of an individual's social and psychological deficits, and treatment focuses on developing personal accountability and responsibility as well as socially productive lives. Treatment is highly structured and can be confrontational at times, with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious and constructive ways to interact with others. Many TCs offer comprehensive services, which can include employment training and other support services, on site. Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, homeless individuals, people with severe mental disorders, and individuals in the criminal justice system (see "Treating Criminal Justice-Involved Drug Abusers and Addicted Individuals").
Further Reading:
Lewis, B.F.; McCusker, J.; Hindin, R.; Frost, R.; and Garfield, F. Four residential drug treatment programs: Project IMPACT. In: J.A. Inciardi, F.M. Tims, and B.W. Fletcher (eds.), Innovative Approaches in the Treatment of Drug Abuse, Westport, CT: Greenwood Press, pp. 45-60, 1993.
Sacks, S.; Banks, S.; McKendrick, K.; and Sacks, J.Y. Modified therapeutic community for co-occurring disorders: A summary of four studies. Journal of Substance Abuse Treatment 34(1):112-122, 2008.
Sacks, S.; Sacks, J.; DeLeon, G.; Bernhardt, A.; and Staines, G. Modified therapeutic community for mentally ill chemical "abusers": Background; influences; program description; preliminary findings. Substance Use and Misuse 32(9):1217-1259, 1997.
Stevens, S.J., and Glider, P.J. Therapeutic communities: Substance abuse treatment for women. In: F.M. Tims, G. DeLeon, and N. Jainchill (eds.), Therapeutic Community: Advances in Research and Application, National Institute on Drug Abuse Research Monograph 144, NIH Pub. No. 94-3633, U.S. Government Printing Office, pp. 162-180, 1994.
Sullivan, C.J.; McKendrick, K.; Sacks, S.; and Banks, S.M. Modified therapeutic community for offenders with MICA disorders: Substance use outcomes. American Journal of Drug and Alcohol Abuse 33(6):823-832, 2007.
Short-Term Residential Treatment
Short-term residential programs provide intensive but relatively brief treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980s, many began to treat other types of substance use disorders. The original residential treatment model consisted of a 3-6-week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as Alcoholics Anonymous. Following stays in residential treatment programs, it is important for individuals to remain engaged in outpatient treatment programs and/or aftercare programs. These programs help to reduce the risk of relapse once a patient leaves the residential setting.
Further Reading:
Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4):291-298, 1998.
Miller, M.M. Traditional approaches to the treatment of addiction. In: A.W. Graham and T.K. Schultz (eds.), Principles of Addiction Medicine (2nd ed.). Washington, D.C.: American Society of Addiction Medicine, 1998.
Outpatient Treatment Programs
Outpatient treatment varies in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for people with jobs or extensive social supports. It should be noted, however, that low-intensity programs may offer little more than drug education. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient's characteristics and needs. In many outpatient programs, group counseling can be a major component. Some outpatient programs are also designed to treat patients with medical or other mental health problems in addition to their drug disorders.
Further Reading:
Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4):291-298, 1998.
Institute of Medicine. Treating Drug Problems. Washington, D.C.: National Academy Press, 1990.
McLellan, A.T.; Grisson, G.; Durell, J.; Alterman, A.I.; Brill, P.; and O'Brien, C.P. Substance abuse treatment in the private setting: Are some programs more effective than others? Journal of Substance Abuse Treatment 10:243-254, 1993.
Simpson, D.D., and Brown, B.S. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4):294-307, 1998.
Individualized Drug Counseling
Individualized drug counseling not only focuses on reducing or stopping illicit drug or alcohol use; it also addresses related areas of impaired functioningsuch as employment status, illegal activity, and family/social relationsas well as the content and structure of the patient's recovery program. Through its emphasis on short-term behavioral goals, individualized counseling helps the patient develop coping strategies and tools to abstain from drug use and maintain abstinence. The addiction counselor encourages 12-step participation (at least one or two times per week) and makes referrals for needed supplemental medical, psychiatric, employment, and other services.
Group Counseling
Many therapeutic settings use group therapy to capitalize on the social reinforcement offered by peer discussion and to help promote drug-free lifestyles. Research has shown that when group therapy either is offered in conjunction with individualized drug counseling or is formatted to reflect the principles of cognitive-behavioral therapy or contingency management, positive outcomes are achieved. Currently, researchers are testing conditions in which group therapy can be standardized and made more community-friendly.
Further Reading:
Crits-Christoph, P.; Gibbons, M.B.; Ring-Kurtz, S.; Gallop, R.; and Present, J. A pilot study of community-friendly manual-guided drug counseling. Journal of Substance Abuse Treatment; 2008 Nov. 26; [Epub ahead of print].
Crits-Christoph, P.; Siqueland, L.; Blaine, J.; Frank, A.; Luborsky, L.; Onken, L.S.; et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry 56(6):493-502, 1999.
Treating Criminal Justice-Involved Drug Abusers and Addicted Individuals
Research has shown that combining criminal justice sanctions with drug treatment can be effective in decreasing drug abuse and related crime. Individuals under legal coercion tend to stay in treatment longer and do as well as or better than those not under legal pressure. Often, drug abusers come into contact with the criminal justice system earlier than other health or social systems, presenting opportunities for intervention and treatment prior to, during, after, or in lieu of incarceration—which may ultimately interrupt and shorten a career of drug use. More information on how the criminal justice system can address the problem of drug addiction can be found in Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide (National Institute on Drug Abuse, revised 2007).
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