What is Addiction?
WHAT IS ADDICTION?
Addiction is characterized by the compulsive use of something, accompanied by loss of control and continued use despite negative or undesirable consequences. An individual who repeatedly uses drugs or alcohol and cannot stop even though he or she is aware of the problems such use causes, is said to be addicted.
A person does not become an addict or “hooked” overnight, despite some popular myths that imply that a single use of a drug can cause a person to become an addict. Some people can control their substance use, using only at certain times or on certain days. People who are addicted, however, continue to use drugs or alcohol and cannot stop until the substance is gone.
Researchers do not know why some users become addicted and others don’t. They do know that anyone who uses drugs can become addicted, and that anyone who uses cocaine or narcotics frequently over a period of time will become addicted.
FACTORS THAT CONTRIBUTE TO ADDICTION
Most experts agree that there are several contributing factors for addiction:
Genetic Predisposition. Some people have a predisposition to drug or alcohol dependency. People who come from families with addiction histories have a greater chance of becoming addicted than those who don’t.
Environment. A person who is surrounded by drug users and drugs is at higher risk for using and becoming addicted. When community attitudes favor drug use, such attitudes may be influential in determining whether or not a person tries drugs.
Society. In subtle ways our society condones and sometimes even encourages drug and alcohol use. We get “do-drug” messages from the glamorizing of drugs and alcohol in movies and other media. We are bombarded with advertising that encourages us to take pills and/or medicines for every ache and pain that ails us. Many experts believe this creates a social climate accepting of drug use.
WHAT IS TREATMENT?
Treatment for addiction consists of a broad range of formal, organized services. Treatment services are provided in both outpatient and residential/inpatient settings, with varying degrees of intensity and duration. While some clients may need longer stays in treatment, progressively less intensive services can be effective for others.
In general, treatment involves the setting of personal goals with a counselor. This almost always includes restoring individuals to a drug-free lifestyle and helping them improve their capacity to function effectively in society. Some programs that target criminal offenders reduce the criminal behavior that supports addiction.
Over the past 25 years, substance abuse treatment has changed in response to an increased understanding of the nature of addiction; increased funding by federal, state, and local governments; an increase in drug use; and changing patterns of use. Citizens in most communities have access to one of the more than 3,500 public and private substance abuse treatment programs in the nation.
There are five major modalities or types of treatment for drug or alcohol abuse: detoxification, residential, intensive outpatient treatment, outpatient, and outpatient methadone treatment. Although there are other types of treatment, in one way or another all fall into one of these five modalities. Treatment is often supplemented by involvement in 12-step support networks such as Alcoholics Anonymous and Narcotics Anonymous.
DETOXIFICATION
Detoxification is a short-term service (usually three to 10 days) that helps a patient withdraw from the physical effects of the abuse of drugs or alcohol. Detoxification reduces the pain, discomfort and possible danger that can result from the abrupt termination of the substance for which the patient has developed a physical dependence. Supportive counseling is always provided in detoxification.
Because of the potential for serious problems associated with withdrawal from alcohol and certain other drugs, patients undergoing detoxification are initially assessed and supervised by trained medical personnel. Once stabilized and free from alcohol or drugs, the individual can continue in the treatment process. For many, detoxification is the first step in the recovery process. Detoxification may be delivered in an outpatient or residential/inpatient basis:
Ambulatory Detoxification: Ambulatory detoxification is an outpatient service, which may be offered in an office setting, community mental health center, methadone maintenance clinic, or addiction treatment facility by trained clinicians. The degree of direct medical management in an ambulatory detoxification setting may vary depending on the client’s level of addiction severity. Ambulatory detoxification has three major advantages: it is less expensive than residential detoxification; it is less disruptive to the client’s life; and, it allows the client to remain in the same environment where he or she will function when drug-free.
Residential/Inpatient Detoxification. Residential/ inpatient detoxification service provides 24-hour supervision, monitoring, and support for clients in withdrawal. While some residential programs provide a greater degree of medical management, other programs emphasize peer and social support when a medically monitored residential/inpatient detoxification service is not necessary. Residential/inpatient detoxification service may be provided in an acute care hospital, residential addic- tions treatment program, psychiatric hospital, or freestanding detoxification center.
Methadone is often used for detoxification from opiates such as heroin, morphine, or Dilaudid. Methadone is a long-lasting, synthetic narcotic prescribed by a physician licensed to dispense methadone. Methadone is substituted for the illegal drug and given orally on a daily basis. By law, detoxification with methadone cannot exceed 180 days.
RESIDENTIAL/INPATIENT TREATMENT
Residential/inpatient treatment takes place in a 24-hour, live-in setting. It is designed for individuals with serious drug or alcohol problems that have resulted in a significant disruption in some aspect of the individual’s life. People entering residential treatment usually have serious problems relating to work, school, family relationships, friends, money, health, or the law. In Florida, there are three levels of residential treatment, as defined by the Florida Administrative Code:
Level I. Short-term treatment not exceeding 60 days that provides a range of assessment, rehabilitation, and support services. Short-term treatment may or may not include formal school or adult education programs.
Level II. Treatment lasting from 61 days to one year that provides the same services as Level I but usually includes educational and vocational services.
Level III Care lasts more than one year. Level III services are the same as Levels I and II, but can be intensive or ongoing. Long-term care facilities for chronic alcoholics are called domiciliaries.
INPATIENT HOSPITALIZATION
Residential treatment provided in a hospital or other medical setting, usually lasting between two and four weeks, is called inpatient hospitalization. This level of care includes 24-hour observation, monitoring, and treatment by physicians and nurses. All residential treatment includes medical and psychosocial assessment, individual and group counseling, and involvement in Alcoholics Anonymous or Narcotics Anonymous.
THERAPEUTIC COMMUNITIES
Therapeutic communities are highly structured residential programs that help clients change their lifestyles, abstain from all drug and alcohol use, eliminate criminal behavior, and develop pro-social behaviors and attitudes. This is accomplished through:
Long-term treatment lasting from six months to two years, depending on the program selected. A system of rewards and punishments where clients earn privileges and assume greater responsibility as they progress in treatment. Intensive counseling in both small and large groups that may be confrontational in nature are avilable. Therapeutic communities emphasize a self-help approach and rely heavily on the use of program graduates as counselors, administrators, and role models. Most therapeutic communities are operated by non-profit agencies under contracts with state or local governments.
HALFWAY HOUSES
Halfway houses are a form of residential treatment where clients live at the program and receive counseling while they work or attend school in the community. Some halfway houses provide a range of vocational and educational services; some rely on other community resources for these services.
INTENSIVE OUTPATIENT TREATMENT
Intensive outpatient treatment consists from at least 9 to 70 hours of treatment weekly provided in an outpatient setting. Clients receive psychosocial and substance abuse assessment. Because of the intense level of care, intensive outpatient treatment can provide a wide range of treatment components. Services may include group therapy, pharmacotherapy, relapse prevention training, individual counseling, family therapy, and vocational training.
Intensive outpatient treatment has been growing in popularity. It helps clients gradually transition from a more intensive level of treatment to a more traditional outpatient treatment. It also allows clients the flexibility of working during the day and attending sessions in the evening or on weekends. Depending on the progress made by the client, a typical program can last from one to six months.
OUTPATIENT TREATMENT
Outpatient treatment is appropriate for individuals whose substance use patterns allow them to remain in their own homes and environments while receiving services. Some outpatient programs are “drug-free,” meaning no psychiatric medication or methadone is administered. Programs that serve dually diagnosed clients (those with both substance abuse and serious mental health problems) sometimes administer psychiatric medication. Outpatient programs that administer methadone are considered a different modality of treatment.
In outpatient treatment, emphasis is placed on individual or group counseling, and sometimes on family counseling. Treatment guidelines are based on individual assessment and treatment goals. Services can range from weekly counseling to intensive counseling provided several times a week. Outpatient counseling can last for two or three months, or can continue for a year or more. Pro- grams range from those that are highly structured to “drop-in” centers.
Many outpatient programs have specific services for special populations such as impaired employees or professionals, criminal offenders, cocaine abusers, and youth. Outpatient programs can be staffed by trained substance abuse counselors, psychologists, or other mental health counselors including social workers to deliver program services. Clients who need additional services such as legal, financial, housing, educational, vocational, and health are usually referred to com- munity resources. Some programs may provide some or all of these support services.
OUTPATIENT METHADONE TREATMENT
Methadone is a synthetic (man-made) drug similar in some ways to other narcotics such as heroin and morphine, but different in other respects. Methadone is physically addictive and can produce severe withdrawal like other narcotics. But when the proper dose of methadone is substituted for heroin (or other narcotics), the addicted individual will not go into withdrawal or get “high.” Individuals stabilized on methadone do not feel intoxicated. They otherwise appear normal and can do things other normal people do, such as drive or operate heavy machinery.
Methadone treatment, which is conducted on an outpatient basis, consists of the daily oral administration of methadone prescribed by a physician in conjunction with regular counseling and other therapeutic services. After the proper dose of methadone has been determined, counseling helps the client regain control of his or her life. After lifestyle changes are successfully made, the client is assisted in withdrawing from the methadone to achieve a drug-free state. Withdrawal from methadone can take from several months to several years.
Counseling is a primary component of most methadone treatment programs, although the range and intensity of these services vary. Most methadone programs focus on practical problem-solving rather than intense personal therapy. Clients are assisted in receiving support services such as vocational, educational, job placement, and legal assistance.
Methadone was approved by the Federal Food and Drug Administration (FDA) in the mid-1960s for use in the treatment of narcotic addiction. Only programs licensed by the FDA, the Drug Enforcement Administration (DEA), and the State Methadone Authority can administer methadone. In Florida, the Department of Health and Rehabilitative Services is the State Methadone Authority.
Methadone clinics vary in size and structure. Some methadone clinics are private for-profit; others are non-profit and supported by state grants and contracts.
EARLY INTERVENTION-KEY TO SUCCESS
One important key to successful treatment is identifying individuals in the early stages of addiction and helping them enroll in appropriate treatment programs. Early intervention focuses on reducing the risk generally associated with the progression of abuse and addiction through early identification, assessment, and supportive counseling targeted toward individuals and their families. Intervention before the onset of long-standing addiction increases the likelihood of a successful outcome. The earlier the intervention, the greater the chance of success has been clearly established.
ASSESSMENT AND REFERRAL
Assessment is the evaluation of a client’s physical and psychosocial condition as it relates to his need for substance abuse services. A thorough assessment must be completed before a client can be referred to the most appropriate treatment modality. There are several components in the assessment process:
A case history is taken of the client’s family background and relationships, education and employment, legal history, and history of drug and alcohol use.
A medical assessment consists of a medical history, and, as necessary, physical exam and laboratory tests.
Diagnostic services such as psychological tests, special educational testing, and psychological or psychiatric evaluation, may be conducted.
Clinical impressions are made, that consist of a summary of cases and recommendations for placement and treatment services.
MATCHING CLIENTS WITH APPROPRIATE TREATMENT
Not every type of treatment will be effective for every client. Treatment must be based on an accurate assessment and the needs of the specific patient. Individuals will respond differently to different treatments based in part on the “type” of drug-dependent person, not just according to the drug of choice. Important variables include the presence of psychiatric problems such as depression, anxiety, or other disorders. Other factors that must be considered are educational and occupational achievements, family and support systems, and family history. In some cases, a combination of treatment methods is necessary to best meet a client’s needs.
One important conclusion of the Treatment Outcome Prospective Study (TOPS) released in 1989 is that no specific type of program has a monopoly on effectiveness. Compatibility with a particular type of treatment is a critical factor, as well as the length of time spent in treatment. Programs emphasizing long-term treatment with re-entry phases help prepare clients for post-treatment success in areas of employment, family relationships, friendships, management of leisure time and drug abstinence. Because of the rising costs of long-term treatment and the increasing numbers of people on treatment waiting lists, traditional programs have become shorter in duration and place greater emphasis on aftercare and relapse prevention efforts.
DOES TREATMENT WORK?
Studies conducted over the past two decades indicate that drug treatment reduces drug use and restores clients to productive lives. Drug treatment can result in a substantial decline in criminal behavior, increased employment and housing, improved personal and interpersonal functioning, and reduced health care costs.
In 1996, the Center for Substance Abuse Treatment (CSAT) published the preliminary results of the National Treatment Improvement Evaluation Study (NTIES), a five-year study of more than 5,000 patients in substance abuse treatment programs. Positive results included:
Increased abstinence. Half of patients who used drugs in the year before treatment did not use drugs the year after treatment.
Reduced involvement in criminal activity by fifty percent.
Decrease in patients who reported receiving welfare income by 13 percent.
Decrease in homelessness among treatment clients from 19 percent to 11 percent.
Increase in the number of clients reporting salary income. One-half of all respondents reported receiving wage or salary income in the year before treatment; 60 percent reported this type of income in the year after treatment.
Decline in reported drug- or alcohol-related medical visits by 53 percent.
Decline in inpatient visits for mental health treatment by 28 percent.
Decline in suicide attempts related to alcohol and other drug use by 40 percent.
Increase in safer sexual behavior. Treatment clients who reported having sex with an IV drug user dropped by half in the year following treatment.
TREATMENT TRENDS
Changes in the profile of individuals seeking and needing treatment have created a challenge for the treatment community in Florida. Dually diagnosed clients, criminal justice offenders, and HIV-infected clients are three major populations that have challenged treatment providers. Today, the majority of treatment admissions are “poly-drug” users (users of multiple substances), a trend different from the drug-specific users of a decade ago. Services targeting these special populations are available throughout Florida.
The increase in cocaine and heroin use has served to underscore that certain groups remain under-served: women, minorities, criminal offenders, the homeless, the dually diagnosed, adolescents, and people lacking the ability to pay the full cost of treatment. Additional resources for prevention and early intervention are needed in many communities.
CONCLUSION
Abstinence from drugs and successful reintegration into society are the achievable goals of treatment. Although methods may vary, counseling remains a cornerstone of treatment, addressing the complex problems associated with drug and alcohol abuse, and enabling clients to re-enter society and lead healthy, productive lives.
Funds for this document are provided by the Substance Abuse Program Office, Florida Department of Children and Families contract #LD079.