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Drug Addiction
Treatment in the United States
General Categories of Treatment Programs
- Agonist Maintenance Treatment for opiate addicts usually
is conducted in outpatient settings, often called methadone treatment
programs. These programs use a long-acting synthetic opiate medication,
usually methadone or LAAM, administered orally for a sustained period
at a dosage sufficient to prevent opiate withdrawal, block the effects
of illicit opiate use, and decrease opiate craving. Patients stabilized
on adequate, sustained dosages of methadone or LAAM can function
normally. They can hold jobs, avoid the crime and violence of the
street culture, and reduce their exposure to HIV by stopping or
decreasing injection drug use and drug-related high-risk sexual
behavior.
Patients stabilized on opiate agonists can engage more readily in
counseling and other behavioral interventions essential to recovery
and rehabilitation. The best, most effective opiate agonist maintenance
programs include individual and/or group counseling, as well as
provision of, or referral to, other needed medical, psychological,
and social services.
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Patients stabilized on adequate
sustained dosages of methadone or LAAM can function normally.
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Further Reading:
Ball, J.C., and Ross, A. The Effectiveness of Methadone Treatment.
New York: Springer-Verlag, 1991.
Cooper, J.R. Ineffective use of psychoactive drugs; Methadone treatment
is no exception. JAMA Jan 8; 267(2): 281-282, 1992.
Dole, V.P.; Nyswander, M.; and Kreek, M.J. Narcotic Blockade. Archives
of Internal Medicine 118: 304-309, 1996.
Lowinson, J.H.; Payte, J.T.; Joseph, H.; Marion, I.J.; and Dole,
V.P. Methadone Maintenance. In: Lowinson, J.H.; Ruiz, P.; Millman,
R.B.; and Langrod, J.G., eds. Substance Abuse: A Comprehensive Textbook.
Baltimore, MD, Lippincott, Williams & Wilkins, 1996, pp. 405-414.
McLellan, A.T.; Arndt, I.O.; Metzger, D.S.; Woody, G.E.; and O'Brien,
C.P. The effects of psychosocial services in substance abuse treatment.
JAMA Apr 21; 269(15): 1953-1959, 1993.
Novick, D.M.; Joseph, J.; Croxson, T.S., et al. Absence of antibody
to human immunodeficiency virus in long-term, socially rehabilitated
methadone maintenance patients. Archives of Internal Medicine Jan;
150(1): 97-99, 1990.
Simpson, D.D.; Joe, G.W.; and Bracy, S.A. Six-year follow-up of
opioid addicts after admission to treatment. Archives of General
Psychiatry Nov; 39(11): 1318-1323, 1982.
Simpson, D.D. Treatment for drug abuse; Follow-up outcomes and
length of time spent. Archives of General Psychiatry 38(8): 875-880,
1981.
- Narcotic Antagonist Treatment Using Naltrexone for opiate
addicts usually is conducted in outpatient settings although initiation
of the medication often begins after medical detoxification in a
residential setting. Naltrexone is a long-acting synthetic opiate
antagonist with few side effects that is taken orally either daily
or three times a week for a sustained period of time. Individuals
must be medically detoxified and opiate-free for several days before
naltrexone can be taken to prevent precipitating an opiate abstinence
syndrome. When used this way, all the effects of self-administered
opiates, including euphoria, are completely blocked. The theory
behind this treatment is that the repeated lack of the desired opiate
effects, as well as the perceived futility of using the opiate,
will gradually over time result in breaking the habit of opiate
addiction. Naltrexone itself has no subjective effects or potential
for abuse and is not addicting. Patient noncompliance is a common
problem. Therefore, a favorable treatment outcome requires that
there also be a positive therapeutic relationship, effective counseling
or therapy, and careful monitoring of medication compliance.
| Patients
stabilized on naltrexone can hold jobs, avoid crime and violence,
and reduce their exposure to HIV. |
Many experienced clinicians have found naltrexone most useful for
highly motivated, recently detoxified patients who desire total
abstinence because of external circumstances, including impaired
professionals, parolees, probationers, and prisoners in work-release
status. Patients stabilized on naltrexone can function normally.
They can hold jobs, avoid the crime and violence of the street culture,
and reduce their exposure to HIV by stopping injection drug use
and drug-related high-risk sexual behavior.
Further Reading:
Cornish, J.W.; Metzger, D.; Woody, G.E.; Wilson, D.; McLellan,
A.T.; Vandergrift, B.; and O'Brien, C.P. Naltrexone pharmacotherapy
for opioid dependent federal probationers. Journal of Substance
Abuse Treatment 14(6): 529-534, 1997.
Greenstein, R.A.; Arndt, I.C.; McLellan, A.T.; and O'Brien, C.P.
Naltrexone: a clinical perspective. Journal of Clinical Psychiatry
45 (9 Part 2): 25-28, 1984.
Resnick, R.B.; Schuyten-Resnick, E.; and Washton, A.M. Narcotic
antagonists in the treatment of opioid dependence: review and commentary.
Comprehensive Psychiatry 20(2): 116-125, 1979.
Resnick, R.B. and Washton, A.M. Clinical outcome with naltrexone:
predictor variables and followup status in detoxified heroin addicts.
Annals of the New York Academy of Sciences 311: 241-246, 1978.
- Outpatient Drug-Free Treatment in the types and intensity
of services offered. Such treatment costs less than residential
or inpatient treatment and often is more suitable for individuals
who are employed or who have extensive social supports. Low-intensity
programs may offer little more than drug education and admonition.
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 is emphasized. Some
outpatient programs are designed to treat patients who have medical
or mental health problems in addition to their drug disorder.
Further Reading:
Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, F.E.; Donham,
R.; and Badger, G.J. Incentives to improve outcome in outpatient
behavioral treatment of cocaine dependence. Archives of General
Psychiatry 51, 568-576, 1994.
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.
- Long-Term Residential Treatment provides care 24 hours
per day, generally in nonhospital settings. The best-known residential
treatment model is the therapeutic community (TC), but residential
treatment may also employ other models, such as cognitive-behavioral
therapy.
TCs are residential programs with planned lengths of stay of
6 to 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 and socially productive lives.
Treatment is highly structured and can at times be confrontational,
with activities designed to help residents examine damaging beliefs,
self-concepts, and patterns of behavior and to adopt new, more
harmonious and constructive ways to interact with others. Many
TCs are quite comprehensive and can include employment training
and other support services on site.
| Therapeutic
communities focus on the "resocialization" of the individual
and use the program's entire "community" as active components
of treatment. |
Compared with patients in other forms of drug treatment, the typical
TC resident has more severe problems, with more co-occurring mental
health problems and more criminal involvement. Research shows that
TCs can be modified to treat individuals with special needs, including
adolescents, women, those with severe mental disorders, and individuals
in the criminal justice system (see Treating
Criminal Justice-Involved Drug Abusers and Addicts ).
Further Reading:
Leukefeld, C.; Pickens, R.; and Schuster, C.R. Improving drug abuse
treatment: Recommendations for research and practice. In: Pickens,
R.W.; Luekefeld, C.G.; and Schuster, C.R., eds. Improving Drug Abuse
Treatment, National Institute on Drug Abuse Research Monograph Series,
DHHS Pub No. (ADM) 91-1754, U.S. Government Printing Office, 1991.
Lewis, B.F.; McCusker, J.; Hindin, R.; Frost, R.; and Garfield,
F. Four residential drug treatment programs: Project IMPACT. In:
Inciardi, J.A.; Tims, F.M.; and Fletcher, B.W. eds. Innovative Approaches
in the Treatment of Drug Abuse. Westport, CN: Greenwood Press, 1993,
pp. 45-60.
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, 1998.
Stevens, S.J., and Glider, P.J. Therapeutic communities: Substance
abuse treatment for women. In: Tims, F.M.; De Leon, G.; and Jainchill,
N., 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, 1994, pp. 162-180.
Stevens, S.; Arbiter, N.; and Glider, P. Women residents: Expanding
their role to increase treatment effectiveness in substance abuse
programs. International Journal of the Addictions 24(5): 425-434,
1989.
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