Pay particular attention to the evidence-based approaches to drug addiction treatment section of the Principles of Drug Addiction Treatment? guide (Modu

I

National Institute on Drug Abuse National Institutes of Health U.S. Department of Health and Human Services

principles of drug addiction

treatment A research-based guide

third edition

II

National Institute on Drug Abuse National Institutes of Health U.S. Department of Health and Human Services

principles of drug addiction

treatment A research-based guide

third edition

iiiiiii iii

Martin W. Adler, Ph.D. Temple University School of Medicine

Kathleen Brady, M.D., Ph.D. Medical University of South Carolina

Greg Brigham, Ph.D. Maryhaven, Inc.

Kathleen M. Carroll, Ph.D. Yale University School of Medicine

Richard R. Clayton, Ph.D. University of Kentucky

Linda B. Cottler, Ph.D. Washington University School of Medicine

David P. Friedman, Ph.D. Wake Forest University Bowman Gray School of Medicine

Reese T. Jones, M.D. University of California at San Francisco

Nancy K. Mello, Ph.D. Harvard Medical School

William R. Miller, Ph.D. University of New Mexico

Charles P. O’Brien, M.D., Ph.D. University of Pennsylvania

Jeffrey Selzer, M.D. Zucker Hillside Hospital

Eric J. Simon, Ph.D. New York University Langone Medical Center

Jose Szapocznik, Ph.D. University of Miami Miller School of Medicine

George Woody, M.D. University of Pennsylvania

The National Institute on Drug Abuse wishes to thank the following individuals for reviewing this publication.

All materials in this volume are in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated.

product or company. Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies described.

NIH Publication No. 12–4180 Printed 1999; Reprinted July 2000, February 2008; Revised April 2009; December 2012

Acknowledgments Contents

ii Acknowledgments

v Preface

2 Principles of Effective Treatment

7 Frequently Asked Questions

7 Why do drug-addicted persons keep using drugs?

8 What is drug addiction treatment?

11 How effective is drug addiction treatment?

12 Is drug addiction treatment worth its cost?

14 How long does drug addiction treatment usually last?

14 What helps people stay in treatment?

15 How do we get more substance- abusing people into treatment?

16 How can family and friends make a difference in the life of someone needing treatment?

16 Where can family members go for information on treatment options?

18 How can the workplace play a role in substance abuse treatment?

19 What role can the criminal justice system play in addressing drug addiction?

20 What are the unique needs of women with substance use disorders?

21 What are the unique needs of pregnant women with substance use disorders?

22 What are the unique needs of adolescents with substance use disorders?

viv

Drug addiction is a complex illness. It is characterized by intense and, at times,

uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. This update of the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment is intended to address addiction to a wide variety of drugs, including nicotine, alcohol, and illicit and prescription drugs. It is designed to serve as a resource for healthcare providers, family members, and other stakeholders trying to address the myriad problems faced by patients in need of treatment for drug abuse or addiction.

Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. That is why addiction is a brain disease. Some individuals are more vulnerable than others to becoming addicted, depending on the interplay between genetic makeup, age

While a person initially chooses to take drugs, over time the effects of prolonged exposure on brain functioning compromise that ability to choose, and seeking and consuming the drug become compulsive, often eluding a person’s self-control or willpower.

But addiction is more than just compulsive drug taking— it can also produce far-reaching health and social consequences. For example, drug abuse and addiction increase a person’s risk for a variety of other mental and physical illnesses related to a drug-abusing lifestyle or the toxic effects of the drugs themselves. Additionally, the dysfunctional behaviors that result from drug abuse can interfere with a person’s normal functioning in the family, the workplace, and the broader community.

Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life, treatment is not simple. Effective treatment programs

Preface

treatments for older adults?

24 Can a person become addicted to medications prescribed by a doctor?

24 Is there a difference between physical dependence and addiction?

25 How do other mental disorders coexisting with drug addiction affect drug addiction treatment?

26 Is the use of medications like methadone and buprenorphine simply replacing one drug addiction with another?

27 Where do 12-step or self-help programs

28 Can exercise play a role in the treatment process?

28 How does drug addiction treatment help reduce the spread of HIV/AIDS, hepatitis C (HCV), and other infectious diseases?

31 Drug Addiction Treatment in the United States

32 Types of Treatment Programs

37 Treating Criminal Justice-Involved Drug Abusers and Addicted Individuals

39 Evidence-Based Approaches to Drug Addiction Treatment

39 Pharmacotherapies

48 Behavioral Therapies

60 Behavioral Therapies Primarily for Adolescents

69 Resources

1vi

typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is a disease, most people cannot simply stop using drugs for a few days and be cured. Patients typically require long-term or repeated episodes of care to achieve the ultimate goal of sustained

research and clinical practice demonstrate the value of continuing care in treating addiction, with a variety of approaches having been tested and integrated in residential and community settings.

As we look toward the future, we will harness new research

gene function and expression (i.e., epigenetics), which are heralding the development of personalized treatment

current evidence supporting the most effective drug abuse and addiction treatments and their implementation, which

Nora D. Volkow, M.D. Director National Institute on Drug Abuse

Nearly four decades of scientific

research and clinical practice

have yielded a variety of effective

approaches to drug addiction treatment.

32

Principles of Effective Treatment

1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences.

2. No single treatment is appropriate for everyone. Treatment varies depending on the type of drug and the characteristics of the patients. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.

3. Treatment needs to be readily available. Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.

4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture.

5. Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of the patient’s problems and needs. Research indicates that most addicted individuals need at least 3 months in

and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a long- term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.

6. Behavioral therapies—including individual, family, or group counseling— are the most commonly used forms of drug abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence.

7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. For example, methadone, buprenorphine, and naltrexone (including a new long-acting formulation) are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Acamprosate,

for treating alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (available as patches, gum, lozenges, or nasal spray) or an oral medication (such as bupropion or varenicline) can be an effective component of treatment when part of a comprehensive behavioral treatment program.

32

54 5

8. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person’s changing needs.

9. Many drug-addicted individuals also have other mental disorders. Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.

10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Although

acute physical symptoms of withdrawal and can, for some, pave the way for effective long-term addiction

addicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment

incentive strategies, begun at initial patient intake, can improve treatment engagement.

4

11. Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment settings, and/or the

entry, retention rates, and the ultimate success of drug treatment interventions.

12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs.

13. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary. Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling focused on reducing infectious disease risk can help patients further reduce or avoid substance- related and other high-risk behaviors. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can facilitate adherence to other medical treatments. Substance abuse treatment facilities should provide onsite, rapid HIV testing rather than referrals to offsite testing— research shows that doing so increases the likelihood that patients will be tested and receive their test results. Treatment providers should also inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drug- abusing populations, and help link them to HIV treatment if they test positive.

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1. Why do drug-addicted persons keep using drugs?

Nearly all addicted individuals believe at the outset that they can stop using drugs on their own, and most try to stop without treatment. Although some people are successful, many attempts result in failure to achieve long- term abstinence. Research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences, including an inability to exert control over the impulse

characteristic of addiction.

Long-term drug use results in significant changes in brain function that can persist long after the individual stops using drugs.

Understanding that addiction has such a fundamental

of achieving and maintaining abstinence without treatment. Psychological stress from work, family problems, psychiatric illness, pain associated with medical problems, social cues (such as meeting individuals from one’s drug- using past), or environmental cues (such as encountering streets, objects, or even smells associated with drug abuse) can trigger intense cravings without the individual even being consciously aware of the triggering event. Any one of these factors can hinder attainment of sustained abstinence and make relapse more likely. Nevertheless, research indicates that active participation in treatment is

even the most severely addicted individuals.

Frequently Asked QuestionsTreatment varies depending on the

type of drug and the characteristics

of the patient. The best programs

provide a combination of therapies

and other services.

9

combination of treatments will vary depending on the patient’s individual needs and, often, on the types of drugs they use.

Drug addiction treatment can include medications, behavioral therapies, or their combination.

Treatment medications, such as methadone, buprenorphine, and naltrexone (including a new long- acting formulation), are available for individuals addicted to opioids, while nicotine preparations (patches, gum, lozenges, and nasal spray) and the medications varenicline and bupropion are available for individuals addicted to

medications available for treating alcohol dependence,1 which commonly co-occurs with other drug addictions, including addiction to prescription medications.

Treatments for prescription drug abuse tend to be similar to those for illicit drugs that affect the same brain systems. For example, buprenorphine, used to treat heroin addiction, can also be used to treat addiction to opioid pain medications. Addiction to prescription stimulants, which affect the same brain systems as illicit stimulants like cocaine, can be treated with behavioral therapies, as there are not yet medications for treating addiction to these types of drugs.

Behavioral therapies can help motivate people to participate in drug treatment, offer strategies for coping with drug cravings, teach ways to avoid drugs and prevent relapse, and help individuals deal with relapse if it occurs. Behavioral therapies can also help people improve communication, relationship, and parenting skills, as well as family dynamics.

2. What is drug addiction treatment?

Drug treatment is intended to help addicted individuals stop compulsive drug seeking and use. Treatment can occur in a variety of settings, take many different forms, and last for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment is

process that involves multiple interventions and regular monitoring.

There are a variety of evidence-based approaches to treating addiction. Drug treatment can include behavioral therapy (such as cognitive-behavioral therapy or contingency management), medications, or

The best treatment programs provide a combination of therapies and other services to meet the needs of the individual patient.

Components of Comprehensive Drug Abuse Treatment

HIV/AIDS Services

Educational Services

Child Care Services

Financial Services

Medical Services

Housing / Transportation

Services Mental Health

Services

Family Services

Vocational Services

Legal Services

Intake Processing/ Assessment

Treatment Plan

Pharmacotherapy

Continuing Care

Clinical and Case

Management

Behavioral Therapy and Counseling

Substance Use Monitoring

Self-Help/Peer Support Groups

8

1 Another drug, topiramate, has also shown promise in studies and is sometimes prescribed (off-label) for this purpose although it has not received FDA approval as a treatment for alcohol dependence.

1110

3. How effective is drug addiction treatment?

In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. For example, methadone treatment has been shown to increase participation in behavioral therapy and decrease both drug use and criminal behavior. However, individual treatment outcomes depend on the extent and nature of the patient’s problems, the appropriateness of treatment and related services used to address those problems, and the quality of interaction between the patient and his or her treatment providers.

Relapse rates for addiction resemble those of other chronic diseases such as diabetes, hypertension, and asthma.

Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction’s powerful disruptive effects on the brain and behavior and to regain control of their lives. The chronic nature of the disease means that relapsing to drug abuse is not only possible but also likely, with symptom recurrence rates similar to those for other well-characterized chronic medical illnesses—such as diabetes, hypertension, and

Between Drug Addiction and Other Chronic Illnesses”)— that also have both physiological and behavioral components.

Many treatment programs employ both individual and group therapies. Group therapy can provide social reinforcement and help enforce behavioral contingencies that promote abstinence and a non-drug-using lifestyle. Some of the more established behavioral treatments, such as contingency management and cognitive-behavioral therapy, are also being adapted for group settings to

particularly in adolescents, there can also be a danger of unintended harmful (or iatrogenic) effects of group treatment—sometimes group members (especially groups of highly delinquent youth) can reinforce drug use and thereby derail the purpose of the therapy. Thus, trained counselors should be aware of and monitor for such effects.

Because they work on different aspects of addiction, combinations of behavioral therapies and medications (when available) generally appear to be more effective than either approach used alone.

Finally, people who are addicted to drugs often suffer from other health (e.g., depression, HIV), occupational, legal, familial, and social problems that should be addressed concurrently. The best programs provide a combination of therapies and other services to meet an individual patient’s needs. Psychoactive medications, such as antidepressants, anti-anxiety agents, mood stabilizers, and antipsychotic medications, may be critical for treatment success when patients have co-occurring mental disorders such as depression, anxiety disorders (including post-traumatic stress disorder), bipolar disorder, or schizophrenia. In addition, most people with severe addiction abuse multiple drugs and require treatment for all substances abused.

Treatment for drug abuse and addiction is delivered in many different settings using a variety of behavioral and pharmacological approaches.

1312

health and social costs by far more than the cost of the treatment itself. Treatment is also much less expensive than its alternatives, such as incarcerating addicted persons. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $24,000 per person.

Drug addiction treatment reduces drug use and its associated health and social costs.

According to several conservative estimates, every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and

greater workplace productivity; and fewer drug-related accidents, including overdoses and deaths.

Unfortunately, when relapse occurs many deem treatment a failure. This is not the case: Successful treatment for addiction typically requires continual evaluation and

for other chronic diseases. For example, when a patient is receiving active treatment for hypertension and symptoms decrease, treatment is deemed successful, even though symptoms may recur when treatment is discontinued. For the addicted individual, lapses to drug abuse do not indicate failure—rather, they signify that treatment needs to be reinstated or adjusted, or that alternate treatment

Evaluated Differently?”).

4. Is drug addiction treatment worth its cost?

Substance abuse costs our Nation over $600 billion annually and treatment can help reduce these costs. Drug addiction treatment has been shown to reduce associated

8

7

6

5

4

3

2

1

0

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5

4

3

2

1

0

Why is addiction treatment evaluated differently? Both require ongoing care

S E

V E

R IT

Y O

F C

O N

D IT

IO N

STAGE OF TREATMENT

PRE PREDURING DURINGPOST POST

Hypertension Treatment Addiction Treatment

DRUG ADDICTION

TYPE I DIABETES

30 to 50%

40 to 60%

HYPERTENSION

50 to 70%

ASTHMA

50 to 70%

Percentage of Patients Who Relapse

Comparison of Relapse Rates Between Drug Addiction and Other Chronic Illnesses

1514

pressure from the criminal justice system, child protection services, employers, or family. Within a treatment program, successful clinicians can establish a positive, therapeutic relationship with their patients. The clinician should ensure that a treatment plan is developed cooperatively with the person seeking treatment, that the plan is followed, and that treatment expectations are clearly understood. Medical, psychiatric, and social services should also be available.

Whether a patient stays in treatment depends on factors associated with both the individual and the program.

Because some problems (such as serious medical or mental illness or criminal involvement) increase the likelihood of patients dropping out of treatment, intensive interventions may be required to retain them. After a course of intensive treatment, the provider should ensure a transition to less intensive continuing care to support and monitor individuals in their ongoing recovery.

7. How do we get more substance- abusing people into treatment?

gap” is massive—that is, among those who need treatment for a substance use disorder, few receive it. In 2011, 21.6 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem, but only 2.3 million received treatment at a specialty substance abuse facility.

Reducing this gap requires a multipronged approach. Strategies include increasing access to effective treatment, achieving insurance parity (now in its earliest phase of implementation), reducing stigma, and raising awareness

5. How long does drug addiction treatment usually last?

Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness,

maintaining positive outcomes. For methadone maintenance, 12 months is considered the minimum, and some opioid-

maintenance for many years.

Good outcomes are contingent on adequate treatment length.

Treatment dropout is one of the major problems encountered by treatment programs; therefore, motivational techniques that can keep patients engaged will also improve outcomes. By viewing addiction as a chronic disease and offering continuing care and monitoring, programs can succeed, but this will often require multiple episodes of treatment and readily readmitting patients that have relapsed.

6. What helps people stay i

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