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NationalInstituteonDrugAbuse(NIDA)

PrinciplesofDrugAddictionTreatment:AResearch-BasedGuide(ThirdEdition)

LastUpdatedJanuary2018

https://www.drugabuse.gov

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TableofContents

PrinciplesofDrugAddictionTreatment:AResearch-BasedGuide(Third

Edition)

Preface

PrinciplesofEffectiveTreatment

FrequentlyAskedQuestions

DrugAddictionTreatmentintheUnitedStates

Evidence-BasedApproachestoDrugAddictionTreatment

Resources

Acknowledgments

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Preface

Drugaddictionisacomplexillness.

Itischaracterizedbyintenseand,attimes,uncontrollabledrug

craving,alongwithcompulsivedrugseekingandusethatpersisteven

inthefaceofdevastatingconsequences.ThisupdateoftheNational

InstituteonDrugAbuse’sPrinciplesofDrugAddictionTreatmentis

intendedtoaddressaddictiontoawidevarietyofdrugs,including

nicotine,alcohol,andillicitandprescriptiondrugs.Itisdesignedto

serveasaresourceforhealthcareproviders,familymembers,and

otherstakeholderstryingtoaddressthemyriadproblemsfacedby

patientsinneedoftreatmentfordrugabuseoraddiction.

Addictionaffectsmultiplebraincircuits,includingthoseinvolvedin

rewardandmotivation,learningandmemory,andinhibitorycontrol

overbehavior.Thatiswhyaddictionisabraindisease.Some

individualsaremorevulnerablethanotherstobecomingaddicted,

dependingontheinterplaybetweengeneticmakeup,ageofexposure

todrugs,andotherenvironmentalinfluences.Whileapersoninitially

choosestotakedrugs,overtimetheeffectsofprolongedexposureon

brainfunctioningcompromisethatabilitytochoose,andseekingand

consumingthedrugbecomecompulsive,ofteneludingaperson’sself-

controlorwillpower.

Butaddictionismorethanjustcompulsivedrugtaking—itcanalso

producefar-reachinghealthandsocialconsequences.Forexample,

drugabuseandaddictionincreaseaperson’sriskforavarietyofother

mentalandphysicalillnessesrelatedtoadrug-abusinglifestyleorthe

toxiceffectsofthedrugsthemselves.Additionally,thedysfunctional

behaviorsthatresultfromdrugabusecaninterferewithaperson’s

normalfunctioninginthefamily,theworkplace,andthebroader

community.

Becausedrugabuseandaddictionhavesomanydimensionsand

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disruptsomanyaspectsofanindividual’slife,treatmentisnotsimple.

Effectivetreatmentprogramstypicallyincorporatemanycomponents,

eachdirectedtoaparticularaspectoftheillnessanditsconsequences.

Addictiontreatmentmusthelptheindividualstopusingdrugs,

maintainadrug-freelifestyle,andachieveproductivefunctioningin

thefamily,atwork,andinsociety.Becauseaddictionisadisease,most

peoplecannotsimplystopusingdrugsforafewdaysandbecured.

Patientstypicallyrequirelong-termorrepeatedepisodesofcareto

achievetheultimategoalofsustainedabstinenceandrecoveryoftheir

lives.Indeed,scientificresearchandclinicalpracticedemonstratethe

valueofcontinuingcareintreatingaddiction,withavarietyof

approacheshavingbeentestedandintegratedinresidentialand

communitysettings.

Aswelooktowardthefuture,wewillharnessnewresearchresultson

theinfluenceofgeneticsandenvironmentongenefunctionand

expression(i.e.,epigenetics),whichareheraldingthedevelopmentof

personalizedtreatmentinterventions.Thesefindingswillbeintegrated

withcurrentevidencesupportingthemosteffectivedrugabuseand

addictiontreatmentsandtheirimplementation,whicharereflectedin

thisguide.

NoraD.Volkow,M.D.

Director

NationalInstituteonDrugAbuse

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PrinciplesofEffective

Treatment

1. Addictionisacomplexbuttreatablediseasethataffects

brainfunctionandbehavior.Drugsofabusealterthebrain’s

structureandfunction,resultinginchangesthatpersistlongafter

drugusehasceased.Thismayexplainwhydrugabusersareat

riskforrelapseevenafterlongperiodsofabstinenceanddespite

thepotentiallydevastatingconsequences.

2. Nosingletreatmentisappropriateforeveryone.Treatment

variesdependingonthetypeofdrugandthecharacteristicsof

thepatients.Matchingtreatmentsettings,interventions,and

servicestoanindividual’sparticularproblemsandneedsiscritical

tohisorherultimatesuccessinreturningtoproductive

functioninginthefamily,workplace,andsociety.

3. Treatmentneedstobereadilyavailable.Becausedrug-

addictedindividualsmaybeuncertainaboutenteringtreatment,

takingadvantageofavailableservicesthemomentpeopleare

readyfortreatmentiscritical.Potentialpatientscanbelostif

treatmentisnotimmediatelyavailableorreadilyaccessible.As

withotherchronicdiseases,theearliertreatmentisofferedinthe

diseaseprocess,thegreaterthelikelihoodofpositiveoutcomes.

4. Effectivetreatmentattendstomultipleneedsofthe

individual,notjusthisorherdrugabuse.Tobeeffective,

treatmentmustaddresstheindividual’sdrugabuseandany

associatedmedical,psychological,social,vocational,andlegal

problems.Itisalsoimportantthattreatmentbeappropriatetothe

individual’sage,gender,ethnicity,andculture.

5. Remainingintreatmentforanadequateperiodoftimeis

critical.Theappropriatedurationforanindividualdependson

thetypeanddegreeofthepatient’sproblemsandneeds.

Researchindicatesthatmostaddictedindividualsneedatleast3

monthsintreatmenttosignificantlyreduceorstoptheirdruguse

andthatthebestoutcomesoccurwithlongerdurationsof

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treatment.Recoveryfromdrugaddictionisalong-termprocess

andfrequentlyrequiresmultipleepisodesoftreatment.Aswith

otherchronicillnesses,relapsestodrugabusecanoccurand

shouldsignalaneedfortreatmenttobereinstatedoradjusted.

Becauseindividualsoftenleavetreatmentprematurely,programs

shouldincludestrategiestoengageandkeeppatientsin

treatment.

6. Behavioraltherapies—includingindividual,family,orgroup

counseling—arethemostcommonlyusedformsofdrug

abusetreatment.Behavioraltherapiesvaryintheirfocusand

mayinvolveaddressingapatient’smotivationtochange,

providingincentivesforabstinence,buildingskillstoresistdrug

use,replacingdrug-usingactivitieswithconstructiveand

rewardingactivities,improvingproblem-solvingskills,and

facilitatingbetterinterpersonalrelationships.Also,participationin

grouptherapyandotherpeersupportprogramsduringand

followingtreatmentcanhelpmaintainabstinence.

7. Medicationsareanimportantelementoftreatmentfor

manypatients,especiallywhencombinedwithcounseling

andotherbehavioraltherapies.Forexample,methadone,

buprenorphine,andnaltrexone(includinganewlong-acting

formulation)areeffectiveinhelpingindividualsaddictedtoheroin

orotheropioidsstabilizetheirlivesandreducetheirillicitdrug

use.Acamprosate,disulfiram,andnaltrexonearemedications

approvedfortreatingalcoholdependence.Forpersonsaddictedto

nicotine,anicotinereplacementproduct(availableaspatches,

gum,lozenges,ornasalspray)oranoralmedication(suchas

bupropionorvarenicline)canbeaneffectivecomponentof

treatmentwhenpartofacomprehensivebehavioraltreatment

program.

8. Anindividual'streatmentandservicesplanmustbe

assessedcontinuallyandmodifiedasnecessarytoensure

thatitmeetshisorherchangingneeds.Apatientmay

requirevaryingcombinationsofservicesandtreatment

componentsduringthecourseoftreatmentandrecovery.In

additiontocounselingorpsychotherapy,apatientmayrequire

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medication,medicalservices,familytherapy,parenting

instruction,vocationalrehabilitation,and/orsocialandlegal

services.Formanypatients,acontinuingcareapproachprovides

thebestresults,withthetreatmentintensityvaryingaccordingto

aperson’schangingneeds.

9. Manydrug-addictedindividualsalsohaveothermental

disorders.Becausedrugabuseandaddiction—bothofwhichare

mentaldisorders—oftenco-occurwithothermentalillnesses,

patientspresentingwithoneconditionshouldbeassessedforthe

other(s).Andwhentheseproblemsco-occur,treatmentshould

addressboth(orall),includingtheuseofmedicationsas

appropriate.

10. Medicallyassisteddetoxificationisonlythefirststageof

addictiontreatmentandbyitselfdoeslittletochange

long-termdrugabuse.Althoughmedicallyassisted

detoxificationcansafelymanagetheacutephysicalsymptomsof

withdrawalandcan,forsome,pavethewayforeffectivelong-

termaddictiontreatment,detoxificationaloneisrarelysufficient

tohelpaddictedindividualsachievelong-termabstinence.Thus,

patientsshouldbeencouragedtocontinuedrugtreatment

followingdetoxification.Motivationalenhancementandincentive

strategies,begunatinitialpatientintake,canimprovetreatment

engagement.

11. Treatmentdoesnotneedtobevoluntarytobeeffective.

Sanctionsorenticementsfromfamily,employmentsettings,

and/orthecriminaljusticesystemcansignificantlyincrease

treatmententry,retentionrates,andtheultimatesuccessofdrug

treatmentinterventions.

12. Druguseduringtreatmentmustbemonitored

continuously,aslapsesduringtreatmentdooccur.Knowing

theirdruguseisbeingmonitoredcanbeapowerfulincentivefor

patientsandcanhelpthemwithstandurgestousedrugs.

Monitoringalsoprovidesanearlyindicationofareturntodrug

use,signalingapossibleneedtoadjustanindividual’streatment

plantobettermeethisorherneeds.

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13. Treatmentprogramsshouldtestpatientsforthepresence

ofHIV/AIDS,hepatitisBandC,tuberculosis,andother

infectiousdiseasesaswellasprovidetargetedrisk-

reductioncounseling,linkingpatientstotreatmentif

necessary.Typically,drugabusetreatmentaddressessomeof

thedrug-relatedbehaviorsthatputpeopleatriskofinfectious

diseases.Targetedcounselingfocusedonreducinginfectious

diseaseriskcanhelppatientsfurtherreduceoravoidsubstance-

relatedandotherhigh-riskbehaviors.Counselingcanalsohelp

thosewhoarealreadyinfectedtomanagetheirillness.Moreover,

engaginginsubstanceabusetreatmentcanfacilitateadherence

toothermedicaltreatments.Substanceabusetreatmentfacilities

shouldprovideonsite,rapidHIVtestingratherthanreferralsto

offsitetesting—researchshowsthatdoingsoincreasesthe

likelihoodthatpatientswillbetestedandreceivetheirtestresults.

Treatmentprovidersshouldalsoinformpatientsthathighlyactive

antiretroviraltherapy(HAART)hasproveneffectiveincombating

HIV,includingamongdrug-abusingpopulations,andhelplink

themtoHIVtreatmentiftheytestpositive.

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FrequentlyAskedQuestions

Treatmentvariesdependingonthetypeofdrugandthe

characteristicsofthepatient.Thebestprogramsprovidea

combinationoftherapiesandotherservices.

Whydodrug-addictedpersons

keepusingdrugs?

Nearlyalladdictedindividualsbelieveattheoutsetthattheycanstop

usingdrugsontheirown,andmosttrytostopwithouttreatment.

Althoughsomepeoplearesuccessful,manyattemptsresultinfailure

toachievelong-termabstinence.Researchhasshownthatlong-term

drugabuseresultsinchangesinthebrainthatpersistlongaftera

personstopsusingdrugs.Thesedrug-inducedchangesinbrain

functioncanhavemanybehavioralconsequences,includingan

inabilitytoexertcontrolovertheimpulsetousedrugsdespiteadverse

consequences—thedefiningcharacteristicofaddiction.

Long-termdruguseresultsinsignificantchangesinbrainfunction

thatcanpersistlongaftertheindividualstopsusingdrugs.

Understandingthataddictionhassuchafundamentalbiological

componentmayhelpexplainthedifficultyofachievingand

maintainingabstinencewithouttreatment.Psychologicalstressfrom

work,familyproblems,psychiatricillness,painassociatedwithmedical

problems,socialcues(suchasmeetingindividualsfromone’sdrug-

usingpast),orenvironmentalcues(suchasencounteringstreets,

objects,orevensmellsassociatedwithdrugabuse)cantriggerintense

cravingswithouttheindividualevenbeingconsciouslyawareofthe

triggeringevent.Anyoneofthesefactorscanhinderattainmentof

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sustainedabstinenceandmakerelapsemorelikely.Nevertheless,

researchindicatesthatactiveparticipationintreatmentisanessential

componentforgoodoutcomesandcanbenefiteventhemostseverely

addictedindividuals.

Whatisdrugaddictiontreatment?

Drugtreatmentisintendedtohelpaddictedindividualsstop

compulsivedrugseekinganduse.Treatmentcanoccurinavarietyof

settings,takemanydifferentforms,andlastfordifferentlengthsof

time.Becausedrugaddictionistypicallyachronicdisorder

characterizedbyoccasionalrelapses,ashort-term,one-timetreatment

isusuallynotsufficient.Formany,treatmentisalong-termprocess

thatinvolvesmultipleinterventionsandregularmonitoring.

Thereareavarietyofevidence-basedapproachestotreatingaddiction.

Drugtreatmentcanincludebehavioraltherapy(suchascognitive-

behavioraltherapyorcontingencymanagement),medications,ortheir

combination.Thespecifictypeoftreatmentorcombinationof

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treatmentswillvarydependingonthepatient’sindividualneedsand,

often,onthetypesofdrugstheyuse.

Drugaddictiontreatmentcanincludemedications,behavioral

therapies,ortheircombination.

Treatmentmedications,suchasmethadone,buprenorphine,and

naltrexone(includinganewlong-actingformulation),areavailablefor

individualsaddictedtoopioids,whilenicotinepreparations(patches,

gum,lozenges,andnasalspray)andthemedicationsvareniclineand

bupropionareavailableforindividualsaddictedtotobacco.Disulfiram,

acamprosate,andnaltrexonearemedicationsavailablefortreating

alcoholdependence, whichcommonlyco-occurswithotherdrug

addictions,includingaddictiontoprescriptionmedications.

Treatmentsforprescriptiondrugabusetendtobesimilartothosefor

illicitdrugsthataffectthesamebrainsystems.Forexample,

buprenorphine,usedtotreatheroinaddiction,canalsobeusedtotreat

addictiontoopioidpainmedications.Addictiontoprescription

stimulants,whichaffectthesamebrainsystemsasillicitstimulantslike

cocaine,canbetreatedwithbehavioraltherapies,astherearenotyet

medicationsfortreatingaddictiontothesetypesofdrugs.

Behavioraltherapiescanhelpmotivatepeopletoparticipateindrug

treatment,offerstrategiesforcopingwithdrugcravings,teachwaysto

avoiddrugsandpreventrelapse,andhelpindividualsdealwithrelapse

ifitoccurs.Behavioraltherapiescanalsohelppeopleimprove

communication,relationship,andparentingskills,aswellasfamily

dynamics.

Manytreatmentprogramsemploybothindividualandgrouptherapies.

Grouptherapycanprovidesocialreinforcementandhelpenforce

behavioralcontingenciesthatpromoteabstinenceandanon-drug-

usinglifestyle.Someofthemoreestablishedbehavioraltreatments,

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suchascontingencymanagementandcognitive-behavioraltherapy,

arealsobeingadaptedforgroupsettingstoimproveefficiencyand

cost-effectiveness.However,particularlyinadolescents,therecanalso

beadangerofunintendedharmful(oriatrogenic)effectsofgroup

treatment—sometimesgroupmembers(especiallygroupsofhighly

delinquentyouth)canreinforcedruguseandtherebyderailthe

purposeofthetherapy.Thus,trainedcounselorsshouldbeawareof

andmonitorforsucheffects.

Becausetheyworkondifferentaspectsofaddiction,combinationsof

behavioraltherapiesandmedications(whenavailable)generally

appeartobemoreeffectivethaneitherapproachusedalone.

Finally,peoplewhoareaddictedtodrugsoftensufferfromotherhealth

(e.g.,depression,HIV),occupational,legal,familial,andsocial

problemsthatshouldbeaddressedconcurrently.Thebestprograms

provideacombinationoftherapiesandotherservicestomeetan

individualpatient’sneeds.Psychoactivemedications,suchas

antidepressants,anti-anxietyagents,moodstabilizers,and

antipsychoticmedications,maybecriticalfortreatmentsuccesswhen

patientshaveco-occurringmentaldisorderssuchasdepression,

anxietydisorders(includingpost-traumaticstressdisorder),bipolar

disorder,orschizophrenia.Inaddition,mostpeoplewithsevere

addictionabusemultipledrugsandrequiretreatmentforall

substancesabused.

Treatmentfordrugabuseandaddictionisdeliveredinmany

differentsettingsusingavarietyofbehavioraland

pharmacologicalapproaches.

Anotherdrug,topiramate,hasalsoshownpromiseinstudiesandis

sometimesprescribed(off-label)forthispurposealthoughithasnot

receivedFDAapprovalasatreatmentforalcoholdependence.

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Howeffectiveisdrugaddiction

treatment?

Inadditiontostoppingdrugabuse,thegoaloftreatmentistoreturn

peopletoproductivefunctioninginthefamily,workplace,and

community.Accordingtoresearchthattracksindividualsintreatment

overextendedperiods,mostpeoplewhogetintoandremainin

treatmentstopusingdrugs,decreasetheircriminalactivity,and

improvetheiroccupational,social,andpsychologicalfunctioning.For

example,methadonetreatmenthasbeenshowntoincrease

participationinbehavioraltherapyanddecreasebothdruguseand

criminalbehavior.However,individualtreatmentoutcomesdependon

theextentandnatureofthepatient’sproblems,theappropriatenessof

treatmentandrelatedservicesusedtoaddressthoseproblems,and

thequalityofinteractionbetweenthepatientandhisorhertreatment

providers.

Relapseratesforaddictionresemblethoseofotherchronic

diseasessuchasdiabetes,hypertension,andasthma.

Likeotherchronicdiseases,addictioncanbemanagedsuccessfully.

Treatmentenablespeopletocounteractaddiction’spowerfuldisruptive

effectsonthebrainandbehaviorandtoregaincontroloftheirlives.

Thechronicnatureofthediseasemeansthatrelapsingtodrugabuse

isnotonlypossiblebutalsolikely,withsymptomrecurrencerates

similartothoseforotherwell-characterizedchronicmedicalillnesses—

suchasdiabetes,hypertension,andasthma(seefigure,"Comparison

ofRelapseRatesBetweenDrugAddictionandOtherChronicIllnesses”)

—thatalsohavebothphysiologicalandbehavioralcomponents.

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Unfortunately,whenrelapseoccursmanydeemtreatmentafailure.

Thisisnotthecase:Successfultreatmentforaddictiontypically

requirescontinualevaluationandmodificationasappropriate,similar

totheapproachtakenforotherchronicdiseases.Forexample,whena

patientisreceivingactivetreatmentforhypertensionandsymptoms

decrease,treatmentisdeemedsuccessful,eventhoughsymptoms

mayrecurwhentreatmentisdiscontinued.Fortheaddictedindividual,

lapsestodrugabusedonotindicatefailure—rather,theysignifythat

treatmentneedstobereinstatedoradjusted,orthatalternate

treatmentisneeded(seefigure,"WhyisAddictionTreatmentEvaluated

Differently?").

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Isdrugaddictiontreatmentworth

itscost?

SubstanceabusecostsourNationover$600billionannuallyand

treatmentcanhelpreducethesecosts.Drugaddictiontreatmenthas

beenshowntoreduceassociatedhealthandsocialcostsbyfarmore

thanthecostofthetreatmentitself.Treatmentisalsomuchless

expensivethanitsalternatives,suchasincarceratingaddictedpersons.

Forexample,theaveragecostfor1fullyearofmethadone

maintenancetreatmentisapproximately$4,700perpatient,whereas1

fullyearofimprisonmentcostsapproximately$24,000perperson.

Drugaddictiontreatmentreducesdruguseanditsassociated

healthandsocialcosts.

Accordingtoseveralconservativeestimates,everydollarinvestedin

addictiontreatmentprogramsyieldsareturnofbetween$4and$7in

reduceddrug-relatedcrime,criminaljusticecosts,andtheft.When

savingsrelatedtohealthcareareincluded,totalsavingscanexceed

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costsbyaratioof12to1.Majorsavingstotheindividualandto

societyalsostemfromfewerinterpersonalconflicts;greaterworkplace

productivity;andfewerdrug-relatedaccidents,includingoverdoses

anddeaths.

Howlongdoesdrugaddiction

treatmentusuallylast?

Individualsprogressthroughdrugaddictiontreatmentatvariousrates,

sothereisnopredeterminedlengthoftreatment.However,research

hasshownunequivocallythatgoodoutcomesarecontingenton

adequatetreatmentlength.Generally,forresidentialoroutpatient

treatment,participationforlessthan90daysisoflimited

effectiveness,andtreatmentlastingsignificantlylongeris

recommendedformaintainingpositiveoutcomes.Formethadone

maintenance,12monthsisconsideredtheminimum,andsomeopioid-

addictedindividualscontinuetobenefitfrommethadonemaintenance

formanyyears.

Goodoutcomesarecontingentonadequatetreatmentlength.

Treatmentdropoutisoneofthemajorproblemsencounteredby

treatmentprograms;therefore,motivationaltechniquesthatcankeep

patientsengagedwillalsoimproveoutcomes.Byviewingaddictionas

achronicdiseaseandofferingcontinuingcareandmonitoring,

programscansucceed,butthiswilloftenrequiremultipleepisodesof

treatmentandreadilyreadmittingpatientsthathaverelapsed.

Whathelpspeoplestayin

treatment?

Becausesuccessfuloutcomesoftendependonaperson’sstayingin

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treatmentlongenoughtoreapitsfullbenefits,strategiesforkeeping

peopleintreatmentarecritical.Whetherapatientstaysintreatment

dependsonfactorsassociatedwithboththeindividualandthe

program.Individualfactorsrelatedtoengagementandretention

typicallyincludemotivationtochangedrug-usingbehavior;degreeof

supportfromfamilyandfriends;and,frequently,pressurefromthe

criminaljusticesystem,childprotectionservices,employers,orfamily.

Withinatreatmentprogram,successfulclinicianscanestablisha

positive,therapeuticrelationshipwiththeirpatients.Theclinician

shouldensurethatatreatmentplanisdevelopedcooperativelywith

thepersonseekingtreatment,thattheplanisfollowed,andthat

treatmentexpectationsareclearlyunderstood.Medical,psychiatric,

andsocialservicesshouldalsobeavailable.

Whetherapatientstaysintreatmentdependsonfactors

associatedwithboththeindividualandtheprogram.

Becausesomeproblems(suchasseriousmedicalormentalillnessor

criminalinvolvement)increasethelikelihoodofpatientsdroppingout

oftreatment,intensiveinterventionsmayberequiredtoretainthem.

Afteracourseofintensivetreatment,theprovidershouldensurea

transitiontolessintensivecontinuingcaretosupportandmonitor

individualsintheirongoingrecovery.

Howdowegetmoresubstance-

abusingpeopleintotreatment?

Ithasbeenknownformanyyearsthatthe"treatmentgap”ismassive

—thatis,amongthosewhoneedtreatmentforasubstanceuse

disorder,fewreceiveit.In2011,21.6millionpersonsaged12orolder

neededtreatmentforanillicitdrugoralcoholuseproblem,butonly2.3

millionreceivedtreatmentataspecialtysubstanceabusefacility.

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Reducingthisgaprequiresamultiprongedapproach.Strategiesinclude

increasingaccesstoeffectivetreatment,achievinginsuranceparity

(nowinitsearliestphaseofimplementation),reducingstigma,and

raisingawarenessamongbothpatientsandhealthcareprofessionals

ofthevalueofaddictiontreatment.Toassistphysiciansinidentifying

treatmentneedintheirpatientsandmakingappropriatereferrals,

NIDAisencouragingwidespreaduseofscreening,briefintervention,

andreferraltotreatment(SBIRT)toolsforuseinprimarycaresettings

throughitsNIDAMEDinitiative.SBIRT,whichevidenceshowstobe

effectiveagainsttobaccoandalcoholuse—and,increasingly,against

abuseofillicitandprescriptiondrugs—hasthepotentialnotonlyto

catchpeoplebeforeseriousdrugproblemsdevelop,butalsotoidentify

peopleinneedoftreatmentandconnectthemwithappropriate

treatmentproviders.

Howcanfamilyandfriendsmake

adifferenceinthelifeofsomeone

needingtreatment?

Familyandfriendscanplaycriticalrolesinmotivatingindividualswith

drugproblemstoenterandstayintreatment.Familytherapycanalso

beimportant,especiallyforadolescents.Involvementofafamily

memberorsignificantotherinanindividual'streatmentprogramcan

strengthenandextendtreatmentbenefits.

Wherecanfamilymembersgofor

informationontreatmentoptions?

Tryingtolocateappropriatetreatmentforalovedone,especially

findingaprogramtailoredtoanindividual'sparticularneeds,canbea

difficultprocess.However,therearesomeresourcestohelpwiththis

process.Forexample,NIDA’shandbookSeekingDrugAbuse

Treatment:KnowWhattoAskoffersguidanceinfindingtheright

treatmentprogram.Numerousonlineresourcescanhelplocatealocal

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programorprovideotherinformation,including:

TheSubstanceAbuseandMentalHealthServicesAdministration

(SAMHSA)maintainsaWebsite(www.findtreatment.samhsa.gov)

thatshowsthelocationofresidential,outpatient,andhospital

inpatienttreatmentprogramsfordrugaddictionandalcoholism

throughoutthecountry.Thisinformationisalsoaccessibleby

calling1-800-662-HELP.

TheNationalSuicidePreventionLifeline(1-800-273-TALK)offers

morethanjustsuicideprevention—itcanalsohelpwithahostof

issues,includingdrugandalcoholabuse,andcanconnect

individualswithanearbyprofessional.

TheNationalAllianceonMentalIllness(www.nami.org)andMental

HealthAmerica(www.mentalhealthamerica.net)arealliancesof

nonprofit,self-helpsupportorganizationsforpatientsandfamilies

dealingwithavarietyofmentaldisorders.BothhaveStateand

localaffiliatesthroughoutthecountryandmaybeespecially

helpfulforpatientswithcomorbidconditions.

TheAmericanAcademyofAddictionPsychiatryandtheAmerican

AcademyofChildandAdolescentPsychiatryeachhavephysician

locatortoolspostedontheirWebsitesataaap.organdaacap.org,

respectively.

Faces&VoicesofRecovery(facesandvoicesofrecovery.org),

foundedin2001,isanadvocacyorganizationforindividualsin

long-termrecoverythatstrategizesonwaystoreachouttothe

medical,publichealth,criminaljustice,andothercommunitiesto

promoteandcelebraterecoveryfromaddictiontoalcoholand

otherdrugs.

ThePartnershipatDrugfree.org(drugfree.org)isanorganization

thatprovidesinformationandresourcesonteendruguseand

addictionforparents,tohelpthempreventandinterveneintheir

children’sdruguseorfindtreatmentforachildwhoneedsit.They

offeratoll-freehelplineforparents(1-855-378-4373).

TheAmericanSocietyofAddictionMedicine(asam.org)isa

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societyofphysiciansaimedatincreasingaccesstoaddiction

treatment.TheirWebsitehasanationwidedirectoryofaddiction

medicineprofessionals.

NIDA’sNationalDrugAbuseTreatmentClinicalTrialsNetwork

(drugabuse.gov/about-nida/organization/cctn/ctn)provides

informationforthoseinterestedinparticipatinginaclinicaltrial

testingapromisingsubstanceabuseintervention;orvisit

clinicaltrials.gov.

NIDA’sDrugPubsResearchDisseminationCenter

(drugpubs.drugabuse.gov)providesbooklets,pamphlets,fact

sheets,andotherinformationalresourcesondrugs,drugabuse,

andtreatment.

TheNationalInstituteonAlcoholAbuseandAlcoholism

(niaaa.nih.gov)providesinformationonalcohol,alcoholuse,and

treatmentofalcohol-relatedproblems

(niaaa.nih.gov/search/node/treatment).

Howcantheworkplaceplayarole

insubstanceabusetreatment?

ManyworkplacessponsorEmployeeAssistancePrograms(EAPs)that

offershort-termcounselingand/orassistanceinlinkingemployeeswith

drugoralcoholproblemstolocaltreatmentresources,includingpeer

support/recoverygroups.Inaddition,therapeuticworkenvironments

thatprovideemploymentfordrug-abusingindividualswhocan

demonstrateabstinencehavebeenshownnotonlytopromotea

continueddrug-freelifestylebutalsotoimprovejobskills,punctuality,

andotherbehaviorsnecessaryforactiveemploymentthroughoutlife.

Urinetestingfacilities,trainedpersonnel,andworkplacemonitorsare

neededtoimplementthistypeoftreatment.

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Whatrolecanthecriminaljustice

systemplayinaddressingdrug

addiction?

Itisestimatedthataboutone-halfofStateandFederalprisonersabuse

orareaddictedtodrugs,butrelativelyfewreceivetreatmentwhile

incarcerated.Initiatingdrugabusetreatmentinprisonandcontinuing

ituponreleaseisvitaltobothindividualrecoveryandtopublichealth

andsafety.Variousstudieshaveshownthatcombiningprison-and

community-basedtreatmentforaddictedoffendersreducestheriskof

bothrecidivismtodrug-relatedcriminalbehaviorandrelapsetodrug

use—which,inturn,netshugesavingsinsocietalcosts.A2009study

inBaltimore,Maryland,forexample,foundthatopioid-addicted

prisonerswhostartedmethadonetreatment(alongwithcounseling)in

prisonandthencontinueditafterreleasehadbetteroutcomes

(reduceddruguseandcriminalactivity)thanthosewhoonlyreceived

counselingwhileinprisonorthosewhoonlystartedmethadone

treatmentaftertheirrelease.

Individualswhoentertreatmentunderlegalpressurehave

outcomesasfavorableasthosewhoentertreatmentvoluntarily.

Themajorityofoffendersinvolvedwiththecriminaljusticesystemare

notinprisonbutareundercommunitysupervision.Forthosewith

knowndrugproblems,drugaddictiontreatmentmayberecommended

ormandatedasaconditionofprobation.Researchhasdemonstrated

thatindividualswhoentertreatmentunderlegalpressurehave

outcomesasfavorableasthosewhoentertreatmentvoluntarily.

Thecriminaljusticesystemrefersdrugoffendersintotreatment

throughavarietyofmechanisms,suchasdivertingnonviolent

offenderstotreatment;stipulatingtreatmentasaconditionof

incarceration,probation,orpretrialrelease;andconveningspecialized

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courts,ordrugcourts,thathandledrugoffensecases.Thesecourts

mandateandarrangefortreatmentasanalternativetoincarceration,

activelymonitorprogressintreatment,andarrangeforotherservices

fordrug-involvedoffenders.

Themosteffectivemodelsintegratecriminaljusticeanddrug

treatmentsystemsandservices.Treatmentandcriminaljustice

personnelworktogetherontreatmentplanning—including

implementationofscreening,placement,testing,monitoring,and

supervision—aswellasonthesystematicuseofsanctionsand

rewards.Treatmentforincarcerateddrugabusersshouldinclude

continuingcare,monitoring,andsupervisionafterincarcerationand

duringparole.Methodstoachievebettercoordinationbetween

parole/probationofficersandhealthprovidersarebeingstudiedto

improveoffenderoutcomes.(Formoreinformation,pleasesee

NIDA’sPrinciplesofDrugAbuseTreatmentforCriminalJustice

Populations:AResearch-BasedGuide[revised2012].)

Whataretheuniqueneedsof

womenwithsubstanceuse

disorders?

Gender-relateddrugabusetreatmentshouldattendnotonlyto

biologicaldifferencesbutalsotosocialandenvironmentalfactors,all

ofwhichcaninfluencethemotivationsfordruguse,thereasonsfor

seekingtreatment,thetypesofenvironmentswheretreatmentis

obtained,thetreatmentsthataremosteffective,andthe

consequencesofnotreceivingtreatment.Manylifecircumstances

predominateinwomenasagroup,whichmayrequireaspecialized

treatmentapproach.Forexample,researchhasshownthatphysical

andsexualtraumafollowedbypost-traumaticstressdisorder(PTSD)is

morecommonindrug-abusingwomenthaninmenseekingtreatment.

Otherfactorsuniquetowomenthatcaninfluencethetreatment

processincludeissuesaroundhowtheycomeintotreatment(as

womenaremorelikelythanmentoseektheassistanceofageneralor

23

mentalhealthpractitioner),financialindependence,andpregnancy

andchildcare.

Whataretheuniqueneedsof

pregnantwomenwithsubstance

usedisorders?

Usingdrugs,alcohol,ortobaccoduringpregnancyexposesnotjustthe

womanbutalsoherdevelopingfetustothesubstanceandcanhave

potentiallydeleteriousandevenlong-termeffectsonexposedchildren.

Smokingduringpregnancycanincreaseriskofstillbirth,infant

mortality,suddeninfantdeathsyndrome,pretermbirth,respiratory

problems,slowedfetalgrowth,andlowbirthweight.Drinkingduring

pregnancycanleadtothechilddevelopingfetalalcoholspectrum

disorders,characterizedbylowbirthweightandenduringcognitive

andbehavioralproblems.

Prenataluseofsomedrugs,includingopioids,maycauseawithdrawal

syndromeinnewbornscalledneonatalabstinencesyndrome(NAS).

BabieswithNASareatgreaterriskofseizures,respiratoryproblems,

feedingdifficulties,lowbirthweight,andevendeath.

Researchhasestablishedthevalueofevidence-basedtreatmentsfor

pregnantwomen(andtheirbabies),includingmedications.For

example,althoughnomedicationshavebeenFDA-approvedtotreat

opioiddependenceinpregnantwomen,methadonemaintenance

combinedwithprenatalcareandacomprehensivedrugtreatment

programcanimprovemanyofthedetrimentaloutcomesassociated

withuntreatedheroinabuse.However,newbornsexposedto

methadoneduringpregnancystillrequiretreatmentforwithdrawal

symptoms.Recently,anothermedicationoptionforopioiddependence,

buprenorphine,hasbeenshowntoproducefewerNASsymptomsin

babiesthanmethadone,resultinginshorterinfanthospitalstays.In

general,itisimportanttocloselymonitorwomenwhoaretryingtoquit

druguseduringpregnancyandtoprovidetreatmentasneeded.

24

Whataretheuniqueneedsof

adolescentswithsubstanceuse

disorders?

Adolescentdrugabusershaveuniqueneedsstemmingfromtheir

immatureneurocognitiveandpsychosocialstageofdevelopment.

Researchhasdemonstratedthatthebrainundergoesaprolonged

processofdevelopmentandrefinementfrombirththroughearly

adulthood.Overthecourseofthisdevelopmentalperiod,ayoung

person’sactionsgofrombeingmoreimpulsivetobeingmorereasoned

andreflective.Infact,thebrainareasmostcloselyassociatedwith

aspectsofbehaviorsuchasdecision-making,judgment,planning,and

self-controlundergoaperiodofrapiddevelopmentduringadolescence

andyoungadulthood.

Adolescentdrugabuseisalsooftenassociatedwithotherco-occurring

mentalhealthproblems.Theseincludeattention-deficithyperactivity

disorder(ADHD),oppositionaldefiantdisorder,andconductproblems,

aswellasdepressiveandanxietydisorders.

Adolescentsarealsoespeciallysensitivetosocialcues,withpeer

groupsandfamiliesbeinghighlyinfluentialduringthistime.Therefore,

treatmentsthatfacilitatepositiveparentalinvolvement,integrateother

systemsinwhichtheadolescentparticipates(suchasschooland

athletics),andrecognizetheimportanceofprosocialpeerrelationships

areamongthemosteffective.Accesstocomprehensiveassessment,

treatment,casemanagement,andfamily-supportservicesthatare

developmentally,culturally,andgender-appropriateisalsointegral

whenaddressingadolescentaddiction.

Medicationsforsubstanceabuseamongadolescentsmayincertain

casesbehelpful.Currently,theonlyaddictionmedicationsapproved

byFDAforpeopleunder18areover-the-countertransdermalnicotine

skinpatches,chewinggum,andlozenges(physicianadviceshouldbe

soughtfirst).Buprenorphine,amedicationfortreatingopioidaddiction

25

thatmustbeprescribedbyspeciallytrainedphysicians,hasnotbeen

approvedforadolescents,butrecentresearchsuggestsitcouldbe

effectiveforthoseasyoungas16.Studiesareunderwaytodetermine

thesafetyandefficacyofthisandothermedicationsforopioid-,

nicotine-,andalcohol-dependentadolescentsandforadolescentswith

co-occurringdisorders.

Aretherespecificdrugaddiction

treatmentsforolderadults?

Withtheagingofthebabyboomergeneration,thecompositionofthe

generalpopulationischangingdramaticallywithrespecttothenumber

ofolderadults.Suchachange,coupledwithagreaterhistoryof

lifetimedruguse(thanpreviousoldergenerations),differentcultural

normsandgeneralattitudesaboutdruguse,andincreasesinthe

availabilityofpsychotherapeuticmedications,isalreadyleadingto

greaterdrugusebyolderadultsandmayincreasesubstanceuse

problemsinthispopulation.Whilesubstanceabuseinolderadults

oftengoesunrecognizedandthereforeuntreated,researchindicates

thatcurrentlyavailableaddictiontreatmentprogramscanbeas

effectiveforthemasforyoungeradults.

Canapersonbecomeaddictedto

medicationsprescribedbya

doctor?

Yes.Peoplewhoabuseprescriptiondrugs—thatis,takingthemina

manneroradoseotherthanprescribed,ortakingmedications

prescribedforanotherperson—riskaddictionandotherserioushealth

consequences.Suchdrugsincludeopioidpainrelievers,stimulants

usedtotreatADHD,andbenzodiazepinestotreatanxietyorsleep

disorders.Indeed,in2010,anestimated2.4millionpeople12orolder

metcriteriaforabuseofordependenceonprescriptiondrugs,the

secondmostcommonillicitdruguseaftermarijuana.Tominimize

26

theserisks,aphysician(orotherprescribinghealthprovider)should

screenpatientsforpriororcurrentsubstanceabuseproblemsand

assesstheirfamilyhistoryofsubstanceabuseoraddictionbefore

prescribingapsychoactivemedicationandmonitorpatientswhoare

prescribedsuchdrugs.Physiciansalsoneedtoeducatepatientsabout

thepotentialriskssothattheywillfollowtheirphysician’sinstructions

faithfully,safeguardtheirmedications,anddisposeofthem

appropriately.

Isthereadifferencebetween

physicaldependenceand

addiction?

Yes.Addiction—orcompulsivedrugusedespiteharmfulconsequences

—ischaracterizedbyaninabilitytostopusingadrug;failuretomeet

work,social,orfamilyobligations;and,sometimes(dependingonthe

drug),toleranceandwithdrawal.Thelatterreflectphysicaldependence

inwhichthebodyadaptstothedrug,requiringmoreofittoachievea

certaineffect(tolerance)andelicitingdrug-specificphysicalormental

symptomsifdruguseisabruptlyceased(withdrawal).Physical

dependencecanhappenwiththechronicuseofmanydrugs—

includingmanyprescriptiondrugs,eveniftakenasinstructed.Thus,

physicaldependenceinandofitselfdoesnotconstituteaddiction,but

itoftenaccompaniesaddiction.Thisdistinctioncanbedifficultto

discern,particularlywithprescribedpainmedications,forwhichthe

needforincreasingdosagescanrepresenttoleranceoraworsening

underlyingproblem,asopposedtothebeginningofabuseoraddiction.

Howdoothermentaldisorders

coexistingwithdrugaddiction

affectdrugaddictiontreatment?

Drugaddictionisadiseaseofthebrainthatfrequentlyoccurswith

27

othermentaldisorders.Infact,asmanyas6in10peoplewithanillicit

substanceusedisorderalsosufferfromanothermentalillness;and

ratesaresimilarforusersoflicitdrugs—i.e.,tobaccoandalcohol.For

theseindividuals,oneconditionbecomesmoredifficulttotreat

successfullyasanadditionalconditionisintertwined.Thus,people

enteringtreatmenteitherforasubstanceusedisorderorforanother

mentaldisordershouldbeassessedfortheco-occurrenceoftheother

condition.Researchindicatesthattreatingboth(ormultiple)illnesses

simultaneouslyinanintegratedfashionisgenerallythebesttreatment

approachforthesepatients.

Istheuseofmedicationslike

methadoneandbuprenorphine

simplyreplacingoneaddiction

withanother?

No.Buprenorphineandmethadoneareprescribedoradministered

undermonitored,controlledconditionsandaresafeandeffectivefor

treatingopioidaddictionwhenusedasdirected.Theyareadministered

orallyorsublingually(i.e.,underthetongue)inspecifieddoses,and

theireffectsdifferfromthoseofheroinandotherabusedopioids.

Heroin,forexample,isofteninjected,snorted,orsmoked,causingan

almostimmediate"rush,"orbriefperiodofintenseeuphoria,that

wearsoffquicklyandendsina"crash."Theindividualthen

experiencesanintensecravingtousethedrugagaintostopthecrash

andreinstatetheeuphoria.

Thecycleofeuphoria,crash,andcraving—sometimesrepeatedseveral

timesaday—isahallmarkofaddictionandresultsinseverebehavioral

disruption.Thesecharacteristicsresultfromheroin’srapidonsetand

shortdurationofactioninthebrain.

28

Asusedinmaintenancetreatment,methadoneandbuprenorphine

arenotheroin/opioidsubstitutes.

Incontrast,methadoneandbuprenorphinehavegradualonsetsof

actionandproducestablelevelsofthedruginthebrain.Asaresult,

patientsmaintainedonthesemedicationsdonotexperiencearush,

whiletheyalsomarkedlyreducetheirdesiretouseopioids.

Ifanindividualtreatedwiththesemedicationstriestotakeanopioid

suchasheroin,theeuphoriceffectsareusuallydampenedor

suppressed.Patientsundergoingmaintenancetreatmentdonot

experiencethephysiologicalorbehavioralabnormalitiesfromrapid

fluctuationsindruglevelsassociatedwithheroinuse.Maintenance

treatmentssavelives—theyhelptostabilizeindividuals,allowing

treatmentoftheirmedical,psychological,andotherproblemssothey

cancontributeeffectivelyasmembersoffamiliesandofsociety.

Wheredo12-steporself-help

programsfitintodrugaddiction

treatment?

Self-helpgroupscancomplementandextendtheeffectsof

professionaltreatment.Themostprominentself-helpgroupsarethose

affiliatedwithAlcoholicsAnonymous(AA),NarcoticsAnonymous(NA),

andCocaineAnonymous(CA),allofwhicharebasedonthe12-step

model.Mostdrugaddictiontreatmentprogramsencouragepatientsto

participateinself-helpgrouptherapyduringandafterformal

treatment.Thesegroupscanbeparticularlyhelpfulduringrecovery,

offeringanaddedlayerofcommunity-levelsocialsupporttohelp

peopleachieveandmaintainabstinenceandotherhealthylifestyle

behaviorsoverthecourseofalifetime.

29

Canexerciseplayaroleinthe

treatmentprocess?

Yes.Exerciseisincreasinglybecomingacomponentofmanytreatment

programsandhasproveneffective,whencombinedwithcognitive-

behavioraltherapy,athelpingpeoplequitsmoking.Exercisemayexert

beneficialeffectsbyaddressingpsychosocialandphysiologicalneeds

thatnicotinereplacementalonedoesnot,byreducingnegative

feelingsandstress,andbyhelpingpreventweightgainfollowing

cessation.Researchtodetermineifandhowexerciseprogramscan

playasimilarroleinthetreatmentofotherformsofdrugabuseis

underway.

Howdoesdrugaddiction

treatmenthelpreducethespread

ofHIV/AIDS,HepatitisC(HCV),

andotherinfectiousdiseases?

Drug-abusingindividuals,includinginjectingandnon-injectingdrug

users,areatincreasedriskofhumanimmunodeficiencyvirus(HIV),

hepatitisCvirus(HCV),andotherinfectiousdiseases.Thesediseases

aretransmittedbysharingcontaminateddruginjectionequipmentand

byengaginginriskysexualbehaviorsometimesassociatedwithdrug

use.EffectivedrugabusetreatmentisHIV/HCVpreventionbecauseit

reducesactivitiesthatcanspreaddisease,suchassharinginjection

equipmentandengaginginunprotectedsexualactivity.Counseling

thattargetsarangeofHIV/HCVriskbehaviorsprovidesanaddedlevel

ofdiseaseprevention.

DrugabusetreatmentisHIVandHCVprevention.

30

Injectiondruguserswhodonotentertreatmentareuptosixtimes

morelikelytobecomeinfectedwithHIVthanthosewhoenterand

remainintreatment.Participationintreatmentalsopresents

opportunitiesforHIVscreeningandreferraltoearlyHIVtreatment.In

fact,recentresearchfromNIDA’sNationalDrugAbuseTreatment

ClinicalTrialsNetworkshowedthatprovidingrapidonsiteHIVtestingin

substanceabusetreatmentfacilitiesincreasedpatients’likelihoodof

beingtestedandofreceivingtheirtestresults.HIVcounselingand

testingarekeyaspectsofsuperiordrugabusetreatmentprogramsand

shouldbeofferedtoallindividualsenteringtreatment.Greater

availabilityofinexpensiveandunobtrusiverapidHIVtestsshould

increaseaccesstotheseimportantaspectsofHIVpreventionand

treatment.