Addiction Treatment

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What is addiction treatment?

Addiction treatment for substance abuse comes in various forms depending on the type of substance used, such as alcohol, heroin, cannabis, opioids, and methamphetamine and is delivered in different types of settings, ranging from intensive outpatient to residential treatment. Factors that influence whether or not a patient completes an addiction treatment program are also taken into consideration when practitioners develop an individualized treatment plan, which consists of recommending treatment settings, evidence-based clinical interventions and adjunctive holistic therapeutic services that would optimize treatment outcomes for the patient. Patient preferences for certain aspects of addiction treatment are directly impacted by patient characteristics(1) which include the following: gender, level of education, economic status, health status, utilization of health care, family situation, ethnicity, and religion.

What are various models of addiction treatment?

1. Harm reduction model
The harm reduction model aims to reduce the negative effects of addictive behaviors associated with substance use by providing alternative interventions to promote safe practices. For example, to reduce the transmission of HIV, a harm reduction approach for intravenous drug users would be a syringe service program (SSP)/needle exchange program (NEP). Medically supervised injection sites have become more widespread in an effort to reduce or prevent the number of deaths resulting from drug overdoses. Research shows that programs using the harm reduction model have effectively reduced morbidity and mortality and decreased risky alcohol consumption in adult populations.

2. Abstinence model
The end goal of abstinence-based addiction treatment is complete avoidance of addictive substances and/or behaviors. It is an all-or-nothing approach to treating substance use, which requires that users completely abstain from engaging in addictive behaviors. For individuals with severe alcohol use disorders, the abstinence approach may mean going through the withdrawal phase whereas the harm reduction approach allows individuals to reduce their alcohol intake while minimizing alcohol withdrawal symptoms. The abstinence model is not for everybody; rather, it is recommended for individuals who are at risk for relapse if they engage in a harm-reduction program. Practitioners also make recommendations based on where the patient is at in his or her stage of recovery. Evidence-based studies generally encourage the integration of harm-reduction and abstinence-based models in addiction treatment. (3)

3. Bio-psycho-social model
This model, developed by George Engel, examines the patient’s early life experiences, genetics, environmental factors, interpersonal relationships and culture as they pertain to the development of the individual’s addiction to drugs and alcohol. Engel revolutionized medical thinking by introducing these psychosocial components to the biomedical treatment model, which integrates psychosocial dimensions with the biological aspects of patients. (4) The social model of addiction treatment promotes self-awareness, emotional regulation and emotional education, which strengthens the relationship between therapists and their patients. (5)

4. Cognitive-behavioral therapy (CBT) model
A form of evidence-based psychotherapy, cognitive-behavioral therapy aims to correct negative thinking patterns that would result in changed behavior. The CBT model is an effective approach in addiction treatment for individuals suffering from substance use disorders, eating disorders, and specific mental health disorders. Patients receiving CBT will grow in self-awareness as they recognize negative cognitions and work on identifying triggers that lead to maladaptive behaviors. Available in individual and group therapy sessions, CBT equips clients with healthier coping mechanisms and strategies to be incorporated in everyday life.

5. 12-step model
Alcoholics Anonymous was the first organization to introduce the community-based twelve-step model for addiction treatment. This program incorporates a spiritual component which encourages all participants, religious and nonreligious, to appeal to a sense of Higher Power (subject to personal interpretations) to help them overcome their addiction over which they have no control. Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA) are among the most widely known groups that incorporate the 12-step model, and they serve as valuable community resources for clients during and after formal addiction treatment.

Addiction treatment: Publicly Funded vs. Private

Publicly funded addiction treatment centers are funded by the government, and generally speaking, because patients do not have to pay out of pocket for addiction treatment, there is often a high demand for services and a very long waiting list. Individuals with substance use disorders need treatment as soon as possible; being placed on a waiting list is problematic for them due to their ambivalence about seeking addiction treatment, their low tolerance for waiting and continuing drug use while waiting. (6)

Public alcohol and other drugs (AOD) treatment programs covered by Medicare and Medicaid are severely limited in what they can offer to clients.(7) Limited funding not only restricts general access to quality addiction treatment programs, but it also creates additional barriers to effective treatment that make it difficult for government-funded treatment centers to recruit and retain qualified staff. A 2003 study surveyed clinical directors and staff who worked in government-funded agencies, and the report showed that poor funding attributed to lack of one-on-one care, excessive paperwork, heavy caseloads and other bureaucratic demands that resulted in suboptimal client care and occupational burnout. (8)

Compared to publicly funded programs, private addiction treatment centers offer a wider range of drug and alcohol rehabilitation programs, though they vary greatly in terms of program availability, costs, and guest experience. They have lower staff-to-client ratios, which means clients would receive more attention from clinicians than those who receive care in a publicly funded addiction treatment program. Some private addiction treatment centers offer dual diagnosis treatment which integrates evidence-based practices with various holistic therapeutic interventions such as art therapy and equine therapy. Studies show that integrated addiction treatment for dual diagnosis yields better client outcomes than those that treat mental health and substance use disorders separately.(9)

Private addiction treatment centers accept employer-based health plans and/or private insurance plans. Examples of major health insurance carriers that cover substance abuse treatment services include Cigna, Blue Cross, Aetna, Blue Shield, and United Healthcare. Whether you are fully insured or self-insured, your insurance coverage and out-of-pocket costs will vary, depending on the carrier. If there’s a substance abuse treatment program that piques your interest, it’s best to contact that addiction treatment center directly to see what’s covered under your specific insurance policy.

If you have no insurance or are underinsured, you can visit the Substance Abuse and Mental Health Services Administration (SAMHSA) website or call their national helpline 1-800-662-HELP (4357). You will receive free referrals to a local state office where you can find state-funded facilities that will accept Medicare, Medicaid, or payment on a sliding fee scale.

Factors in Addiction Treatment Drop-Out

A review of research literature from 1992 to 2013 identifies risk factors associated with dropout rates in addiction treatment, which are as follows: cognitive deficits, personality disorder, younger age, and low treatment alliance. One of the most important risk factors to be addressed is the bond between the therapist and the client. The therapeutic alliance between client and therapist is affected by the client’s expectations and perceived credibility of the therapist, the therapist’s ability to use non-verbal techniques to connect with a client and the treatment modality employed by the therapist.(6) Low treatment alliance could also be affected by staff-to-client ratios if each staff member is assigned to multiple cases. The importance of the therapeutic alliance is further supported by a study published in the Journal of Addiction Research and Therapy, which revealed a relationship between the severity of substance use disorders and premature withdrawal from a treatment program. In examining the retention rates of 191 participants, researchers have found some predictable factors in treatment dropouts. The authors strongly believe that when an individual is at high risk for premature withdrawal, directing the individual to a more supportive environment that strengthens the therapeutic relationship will increase readiness for treatment.

Keys to Addiction Treatment Completion

To improve the clients’ success rates of program completion, addiction treatment providers may want to consider integrating services and address some of the following key areas that challenge treatment outcomes: access to treatments, the appropriate level of care, availability of service selections afforded by the provider, and continuity of care after program completion. (7) Access to treatment refers to the process by which an individual contacts a treatment provider, receives an evaluation and engages in a treatment program that is best suited to his or her needs. Within addiction treatment, there are five different levels of care, starting with an early intervention service and proceeding to outpatient services,  intensive/outpatient services, residential treatment, and medically managed intensive inpatient services. After the initial assessment, the practitioner will determine the level of care and length of treatment appropriate for the client. State-funded agencies offer a limited variety of therapy programs compared to private licensed and accredited addiction treatment providers. The types of therapy programs made available to clients can affect the quality of client care and, ultimately, the retention and completion rates. The continuity of care after program completion, which is often referred to as alumni aftercare programs, ensures the success of client recovery and wellness long after program completion. It strengthens the therapeutic alliance and helps minimize the risk of relapse.

Addiction Statistics and Facts

The Center for Behavioral Health Statistics and Quality (CBHSQ) Report, published by the Substance Abuse and Mental Health Services Administration (SAMHSA), provides governmental data collected from sources such as National Surveys on Drug Use and Health which measure rates of substance use, emergency department (ED) visits, and access to addiction treatment. This section presents facts from the CBHSQ Report on substance abuse in college students, working professionals, and older adults.

Substance Use in College Students
The CBHSQ Short Report, published on May 26, 2016, surveyed full-time and part-time college students (ages 18 to 22). Survey respondents were asked about their use of alcohol and illicit substances, which fall under nine categories: marijuana, cocaine, heroin, hallucinogens, inhalants, tranquilizers, stimulants, sedatives and misuse of prescription painkillers. The data were collected from the 2011 to 2014 National Survey on Drug Use and Health (NSDUH) and are as follows:

• On an average day in 2016, about 2,179 full-time college students drank alcohol for the first time, and 1,326 tried an illicit drug for the first time. Among part-time students, 453 had their first drink and 174 initiated use of an illicit drug.
• On an average day in the United States, out of 9 million full-time college students, approximately 1.2 million consumed alcohol and 703,759 used marijuana. Among 2 million part-time college students, 239,212 consumed alcohol and 195,020 used marijuana.

Substance Use by Industry
This CBHSQ Report, published on the SAMHSA website on April 16, 2015, reviews data from surveys collected in 2008 through 2012 that examined rates of substance use in 19 industries. Survey respondents, aged 18-64, were employed full-time (at a minimum of 35 hours per week).

• Combined data from 2008 to 2012 show an estimated annual average of 8.7% of full-time professionals who used alcohol heavily within the past month of taking the survey; 8.6% used illicit drugs within the past month and 9.5% were chemically dependent within the past year.
• With regard to heavy alcohol consumption within the past month of taking the survey, the mining and construction industries ranked the highest
• With regard to illicit drug use, the accommodations and food services industry had the highest rates of substance use disorders within the past year of the survey

Substance Use in Older Adults
The data in the 2017 issue of the CBHSQ Report comes from the National Survey on Drug Use and Health (NSDUH), the Treatment of Episode Data Set (TEDS), and the Drug Abuse Warning Network (DAWN). These data sources reveal information about substance use in older adults (aged 65 and over), their admissions to addiction treatment and emergency department (ED) visits for substance use.

• From 2007 to 2014, national surveys reveal that on any given day during the past month, 6 million older adults consumed alcohol; 132,000 used marijuana and 4,300 used cocaine.
• The 2012 TEDS report indicates that on an average day in 2012, 29 admissions to addiction treatment were reported for older adults with regard to alcohol use, and 6 admissions were reported for use of heroin or other opiates.
• In 2011 on an average day, out of the 2,056 drug-related ED visits for older adults, 290 were associated with illegal drug use, misuse of prescription drugs, or use of alcohol combined with other drugs (DAWN, 2011)

References

1. Newton-Howes, G., & Stanley, J. (2015). Patient characteristics and predictors of completion in residential treatment for substance use disorders. BJPsych bulletin, 39(5), 221-7.

2. Harm reduction: An approach to reducing risky health behaviors in adolescents. (2008). Pediatrics & child health, 13(1), 53-60.

3. Oyemade A. (2015). Opioid abuse and overdose crisis: new treatment available-controversy continues between harm-reduction treatment and abstinence treatment. Innovations in clinical neuroscience, 12(3-4), 10-1.

4. SMITH R. C. (2002). The Biopsychosocial Revolution: Interviewing and Provider-patient Relationships Becoming Key Issues for Primary Care. Journal of General Internal Medicine, 17(4), 309–310.

5. Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Annals of family medicine, 2(6), 576-82.

6. Chun, J., Guydish, J. R., Silber, E., & Gleghorn, A. (2008). Drug treatment outcomes for persons on waiting lists. The American journal of drug and alcohol abuse, 34(5), 526-33.

7. Stewart, M. T., & Horgan, C. H. (2011). Health services and financing of treatment. Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism, 33(4), 389-94.

8. Pullen, E., & Oser, C. (2014). Barriers to substance abuse treatment in rural and urban communities: counselor perspectives. Substance use & misuse, 49(7), 891-901.

9. Padwa, H., Larkins, S., Crevecoeur-Macphail, D. A., & Grella, C. E. (2013). Dual Diagnosis Capability in Mental Health and Substance Use Disorder Treatment Programs. Journal of dual diagnosis, 9(2), 179-186.

10. Roth, A. & Fonagy, P., (2006) What works for Whom? A Critical Review of Psychotherapy Research, The Guilford Press, New York & London

11. Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 42.) 3 Keys to Successful Programming. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64185/

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