|
Drug rehabilitation |
| Intervention |
|
ICD-9-CM |
94.64 |
Drug rehabilitation (often drug rehab or just rehab)
is a term
for the processes of medical or psychotherapeutic treatment, for
dependency on
psychoactive substances such as
alcohol,
prescription
drugs, and
street drugs such as
cocaine,
heroin
or
amphetamines. The general intent is to enable the patient to cease
substance abuse, in order to avoid the psychological, legal, financial,
social, and physical consequences that can be caused, especially by
extreme abuse.
Psychological dependency
Psychological dependency is addressed in many drug rehabilitation
programs by attempting to teach the patient new methods of interacting
in a drug-free environment. In particular, patients are generally
encouraged, or possibly even required, to not associate with friends who
still use the addictive substance.
Twelve-step programs encourage addicts not only to stop using
alcohol or other drugs, but to examine and change habits related to
their
addictions. Many programs emphasize that recovery is a permanent
process without culmination. For legal drugs such as alcohol, complete
abstention—rather than attempts at
moderation, which may lead to relapse—is also emphasized ("One is
too many, and a thousand is never enough.") Whether moderation is
achievable by those with a history of abuse remains a controversial
point, but is generally considered unsustainable.[citation
needed]
Types of treatment
Various types of programs offer help in drug rehabilitation,
including: residential treatment (in-patient), out-patient, local
support groups, extended care centers, recovery or
sober houses, addiction counselling, mental health, orthomolecular
medicine and medical care. Some rehab centers offer age- and
gender-specific programs.
In a survey of treatment providers from three separate institutions
(the National Association of Alcoholism and Drug Abuse Counselors,
Rational Recovery Systems and the Society of Psychologists in Addictive
Behaviors)[where?]
measuring the treatment provider's responses on the Spiritual Belief
Scale (a scale measuring belief in the four spiritual characteristics AA
identified by Ernest Kurtz); the scores were found to
explain 41% of the
variance in the treatment provider's responses on the Addiction
Belief Scale (a scale measuring adherence to the
disease model or the free-will model addiction).[1]
Scientific research since 1970 shows that effective treatment
addresses the multiple needs of the patient rather than treating
addiction alone.[citation
needed] In addition, medically assisted
detoxification alone is ineffective as a treatment for addiction.[citation
needed] The National Institute on Drug Abuse (NIDA)
recommends detoxification followed by both medication (where applicable)
and behavioral therapy, followed by relapse prevention. According to
NIDA, effective treatment must address medical and mental health
services as well as follow-up options, such as community or family based
recovery support systems.[2]
Whatever the methodology, patient motivation is an important factor in
treatment success.
For individuals addicted to prescription drugs, treatments tend to be
similar to those who are addicted to drugs affecting the same brain
systems. Medication like
methadone and
buprenorphine can be used to treat addiction to prescription
opiates, and behavioral therapies can be used to treat addiction to
prescription stimulants, benzodiazepines, and other drugs.[3]
Types of behavioral therapy include:
Cognitive-behavioral therapy, which seeks to help patients to
recognize, avoid and cope with situations in which they are most likely
to relapse.
Multidimensional family therapy, which is designed to support
recovery of the patient by improving family functioning.
Motivational interviewing, which is designed to increase patient
motivation to change behavior and enter treatment.[4]
Motivational incentives, which uses positive reinforcement to
encourage abstinence from the addictive substance.[5]
The Substance Abuse and Mental Health Services Administration has
provided a list of programs and institutions that offer diverse
treatments according to the age group, type of addiction and other
aspects. Among these programs can be found: Partners for Recovery (PFR),
Medication Assisted Treatment (MAT), Recovery Community Services Program
(RCSP), and the National Center on Substance Abuse and Child Welfare
(NCSACW).[6]
Pharmacotherapies
Certain opioid medications such as
methadone and more recently
buprenorphine (In America, "Subutex"
and "Suboxone")
are widely used to treat addiction and dependence on other opioids such
as heroin,
morphine or
oxycodone.
Methadone and buprenorphine are maintenance therapies intended to
reduce cravings for opiates, thereby reducing
illegal drug use, and the risks associated with it, such as
disease,
arrest,
incarceration, and
death, in
line with the philosophy of
harm reduction. Both drugs may be used as maintenance medications
(taken for an indefinite period of time), or used as
detoxification aids.[7]
All available studies collected in the 2005 Australian National
Evaluation of Pharmacotherapies for Opioid Dependence suggest that
maintenance treatment is preferable,[7]
with very high rates (79–100%)[7]
of
relapse within three months of detoxification from
LAAM, buprenorphine, and methadone.[7][8]
Ibogaine is a
hallucinogenic drug promoted by certain fringe groups to interrupt
both physical dependence and psychological craving to a broad range or
drugs including narcotics, stimulants, alcohol and nicotine. To date,
there have never been any controlled studies showing it to be effective,
and it is accepted as a treatment by no association of physicians,
pharmacists, or addictionologists. There have been several deaths
related to ibogaine use, which causes
tachycardia and
long QT syndrome. The drug is an illegal Schedule I controlled
substance in the United States, and the foreign facilities in which it
is administered tend to have little oversight, and range from motel
rooms to one moderately-sized rehabilitation center.[9]
Some antidepressants also show usefulness in moderating drug use,
particularly to nicotine, and it has become common for researchers to
re-examine already approved drugs for new uses in drug rehabilitation.
According to the
National Institute on Drug Abuse (NIDA), patients stabilized on
adequate, sustained doses of methadone or buprenorphine can keep their
jobs, avoid
crime and
violence, and reduce their exposure to
HIV and
Hepatitis C by stopping or reducing injection drug use and
drug-related high risk
sexual behavior.
Naltrexone is a long-acting
opioid antagonist with few side effects,[dubious
–
discuss][citation
needed] and it's usually prescribed in
outpatient medical conditions; even though initiation of the
treatment begins after medical detoxification in a residential setting.
Naltrexone blocks the euphoric and all other effects of
self-administered (and physician-administered) pills or injections
(leaving the patient at a loss if he requires unplanned
surgery
or another
painful procedure or condition requiring
pain control or even
general anaesthesia, as the chemicals,
fentanil and
sufentanil, most commonly used to induce anaesthesia are also
opioids which are blocked).[citation
needed] It has also been used as treatment for
alcohol addiction.[citation
needed] Specialists[who?]
claim that Naltrexone cuts relapse risk during the first 3 months by
about 36%.[dubious
–
discuss][citation
needed] However, it is far less effective in
helping patients maintain abstinence or retaining them in the
drug-treatment system (retention rates average 12% at 90 days for
naltrexone, average 57% at 90 days for buprenorphine, average 61% at 90
days for methadone).[7]
Acamprosate,
disulfiram and
topiramate (a novel
anticonvulsant
sulphonated sugar) are also used to treat alcohol addiction.
Acamprosate has shown effectiveness for patients with severe dependence,
helping them to maintain abstinence for several weeks or months.[citation
needed] Disulfiram (also called Antabuse) produces
a very unpleasant reaction when drinking alcohol that includes flushing,
nausea and palpitations. It is more effective for patients with high
motivation and some addicts use it only for high risk situations.[10]
Nitrous oxide has been shown to be an effective treatment for a
number of addictions.[11][12][13]
Experimental
treatment
The Nature of Things, a
CBC Television program by
David Suzuki, explored an experimental drug treatment by Dr.
Gabor Maté who works with addicts in
Vancouver which uses the substance
Ayawaska.[14]
Criminal justice
Drug rehabilitation is sometimes part of the
criminal justice system. People convicted of minor drug offenses may
be sentenced to rehabilitation instead of prison, and those convicted of
driving while intoxicated are sometimes required to attend
Alcoholics Anonymous meetings. There are a number of ways to address
an alternative sentence in a drug possession or DUI case; increasingly,
American courts are willing to explore outside-the-box methods for
delivering this service. There have been lawsuits filed, and won,
regarding the requirement of attending Alcoholics Anonymous and other
twelve-step meetings as being inconsistent with the Establishment Clause
of the First Amendment of the U. S. Constitution, mandating separation
of church and state.[15][16]
Counseling
Traditional addiction treatment is based primarily on counseling.
However, recent discoveries have shown those suffering from addiction
often have chemical imbalances that make the recovery process more
difficult.
Counselors help individuals identifying behaviors and problems
related to their addiction. It can be done on an individual basis, but
it's more common to find it in a group setting and can include crisis
counseling, weekly or daily counseling, and drop-in counseling supports.
They are trained to develop recovery programs that help to reestablish
healthy behaviors and provide coping strategies whenever a situation of
risk happens. It's very common to see them work also with family members
who are affected by the addictions of the individual, or in a community
in order to prevent addiction and educate the public. Counselors should
be able to recognize how addiction affects the whole person and those
around him or her.[17]
Counseling is also related to "Intervention"; a process in which the
addict's family requests help from a professional in order to get this
person into drug treatment. This process begins with one of this
professionals' first goals: breaking down denial of the person with the
addiction. Denial implies lack of willingness from the patients or fear
to confront the true nature of the addiction and to take any action to
improve their lives, besides of continuing the destructive behavior.
Once this has been achieved, professional coordinates with the addict's
family to support them on getting this family member to alcohol drug
rehabilitation immediately, with concern and care for this person.
Otherwise, this person will be asked to leave and expect no support of
any kind until going into drug rehabilitation or alcoholism treatment.
An intervention can also be conducted in the workplace environment with
colleagues instead of family.
One approach with limited applicability is the
Sober Coach. In this approach, the client is serviced by provider(s)
in his or her home and workplace — for any efficacy, around-the-clock —
who functions much like a
nanny to
guide or control the patient's behavior.
Historical approaches to substance abuse treatment
Disease model and twelve-step programs
The
disease model of addiction has long contended the maladaptive
patterns of alcohol and substance use displayed by addicted individuals
are the result of a lifelong disease that is biological in origin and
exacerbated by environmental contingencies. This conceptualization
renders the individual essentially powerless over his or her problematic
behaviors and unable to remain sober by himself or herself, much as
individuals with a terminal illness are unable to fight the disease by
themselves without medication. Behavioral treatment, therefore,
necessarily requires individuals to admit their addiction, renounce
their former lifestyle, and seek a supportive social network who can
help them remain sober. Such approaches are the quintessential features
of
Twelve-step programs, originally published in the book Alcoholics
Anonymous in 1939.[18]
These approaches have met considerable amounts of criticism, coming from
opponents who disapprove of the spiritual-religious orientation on both
psychological
[19] and legal
[20] grounds. Nonetheless, despite this criticism, outcome
studies have revealed that affiliation with twelve-step programs
predicts abstinence success at 1-year follow-up for alcoholism.
Different results have been reached for other drugs, with the twelve
steps being less beneficial for addicts to illicit substances, and least
beneficial to those addicted to the physiologically and psychologically
addicting
opioids, for which
maintenance therapies are the gold standard of care.[21]
Client-centered approaches
In his influential book, Client-Centered Therapy, in which he
presented the
client-centered approach to therapeutic change, psychologist Carl
Rogers proposed there are three necessary and sufficient conditions for
personal change: unconditional positive regard, accurate empathy, and
genuineness. Rogers believed the presence of these three items in the
therapeutic relationship could help an individual overcome any
troublesome issue, including
alcohol abuse. To this end, a 1957 study
[22] compared the relative effectiveness of three different
psychotherapies in treating alcoholics who had been committed to a state
hospital for sixty days: a therapy based on
two-factor learning theory,
client-centered therapy, and
psychoanalytic therapy. Though the authors expected the two-factor
theory to be the most effective, it actually proved to be deleterious in
outcome. Surprisingly, client-centered therapy proved most effective. It
has been argued, however, these findings may be attributable to the
profound difference in therapist outlook between the two-factor and
client-centered approaches, rather than to client-centered techniques
per se.[23]
The authors note two-factor theory involves stark disapproval of the
clients’ “irrational behavior” (p. 350); this notably negative outlook
could explain the results.
A variation of Rogers' approach has been developed in which clients
are directly responsible for determining the goals and objectives of the
treatment. Known as Client-Directed Outcome-Informed therapy (CDOI),
this approach has been utilized by several drug treatment programs, such
as Arizona's Department of Health Services.[24]
Psychoanalytic approaches
Psychoanalysis, a psychotherapeutic approach to behavior change
developed by
Sigmund Freud and modified by his followers, has also offered an
explanation of
substance abuse. This orientation suggests the main cause of the
addiction syndrome is the unconscious need to entertain and to enact
various kinds of homosexual and perverse fantasies, and at the same time
to avoid taking responsibility for this. It is hypothesised specific
drugs facilitate specific fantasies and using drugs is considered to be
a displacement from, and a concomitant of, the compulsion to masturbate
while entertaining homosexual and perverse fantasies. The addiction
syndrome is also hypothesised to be associated with life trajectories
that have occurred within the context of traumatogenic processes, the
phases of which include social, cultural and political factors,
encapsulation, traumatophilia, and masturbation as a form of
self-soothing.[25]
Such an approach lies in stark contrast to the approaches of
social cognitive theory to addiction—and indeed, to behavior in
general—which holds human beings regulate and control their own
environmental and cognitive environments, and are not merely driven by
internal, driving impulses. Additionally, homosexual content is not
implicated as a necessary feature in addiction.
Cognitive models of addiction recovery
Relapse prevention
An influential
cognitive-behavioral approach to addiction recovery and therapy has
been Alan Marlatt’s (1985) Relapse Prevention approach.[26]
Marlatt describes four psychosocial processes relevant to the addiction
and
relapse processes:
self-efficacy, outcome expectancies, attributions of causality, and
decision-making processes. Self-efficacy refers to one’s ability to deal
competently and effectively with high-risk, relapse-provoking
situations. Outcome expectancies refer to an individual’s expectations
about the
psychoactive effects of an addictive substance. Attributions of
causality refer to an individual’s pattern of beliefs that relapse to
drug use is a result of internal, or rather external, transient causes
(e.g., allowing oneself to make exceptions when faced with what are
judged to be unusual circumstances). Finally, decision-making processes
are implicated in the relapse process as well. Substance use is the
result of multiple decisions whose collective effects result in
consumption of the intoxicant. Furthermore, Marlatt stresses some
decisions—referred to as apparently irrelevant decisions—may seem
inconsequential to relapse, but may actually have downstream
implications that place the user in a high-risk situation.
For example: As a result of heavy traffic, a recovering alcoholic may
decide one afternoon to exit the highway and travel on side roads. This
will result in the creation of a high-risk situation when he realizes he
is inadvertently driving by his old favorite bar. If this individual is
able to employ successful
coping strategies, such as distracting himself from his cravings by
turning on his favorite music, then he will avoid the relapse risk (PATH
1) and heighten his efficacy for future abstinence. If, however, he
lacks coping mechanisms—for instance, he may begin ruminating on his
cravings (PATH 2)—then his efficacy for abstinence will decrease, his
expectations of positive outcomes will increase, and he may experience a
lapse—an isolated return to substance intoxication. So doing results in
what Marlatt refers to as the Abstinence Violation Effect, characterized
by guilt for having gotten intoxicated and low efficacy for future
abstinence in similar tempting situations. This is a dangerous pathway,
Marlatt proposes, to full-blown relapse.
Cognitive therapy of substance abuse
An additional cognitively-based model of substance abuse recovery has
been offered by
Aaron Beck, the father of
cognitive therapy and championed in his 1993 book, Cognitive Therapy
of Substance Abuse.[27]
This therapy rests upon the assumption addicted individuals possess core
beliefs, often not accessible to immediate consciousness (unless the
patient is also depressed). These core beliefs, such as “I am
undesirable,” activate a system of addictive beliefs that result in
imagined anticipatory benefits of substance use and, consequentially,
craving. Once craving has been activated, permissive beliefs (“I can
handle getting high just this one more time”) are facilitated. Once a
permissive set of beliefs have been activated, then the individual will
activate drug-seeking and drug-ingesting behaviors. The cognitive
therapist’s job is to uncover this underlying system of beliefs, analyze
it with the patient, and thereby demonstrate its dysfunctionality. As
with any cognitive-behavioral therapy, homework assignments and
behavioral exercises serve to solidify what is learned and discussed
during treatment.
Emotion regulation, mindfulness and substance abuse
A growing literature is demonstrating the importance of
emotion regulation in the treatment of substance abuse. For the sake
of conceptual uniformity, this section uses the tobacco cessation as the
chief example; however, since
nicotine and other psychoactive substances such as
cocaine
activate similar psychopharmacological pathways,[28]
an emotion regulation approach may be similarly applicable to a wider
array of substances of abuse. Proposed models of affect-driven tobacco
use have focused on
negative reinforcement as the primary driving force for addiction;
according to such theories, tobacco is used because it helps one escape
from the undesirable effects of
nicotine withdrawal or other negative moods.[29]
Currently, research is being conducted to determine the efficacy of
mindfulness based approaches to smoking cessation, in which patients
are encouraged to identify and recognize their negative emotional states
and prevent the maladaptive, impulsive/compulsive responses they have
developed to deal with them (such as cigarette smoking or other
substance use).[29]
Behavioral models
Behavioral models make use of principles of functional analysis of
drinking behavior. Behavior models exists for both working with the
substance abuser (Community reinforcement approach) and their family
(community reinforcement and family training). Both these models have
had considerable research success for both efficacy and effectiveness.
This model lays much emphasis on the use of problem solving techniques
as a means of helping the addict to overcome his addiction.
See also