| Drug Rehabilitation | |
|---|---|
| ICD-9-CM | 94.64 |
Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and cease substance abuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.
Treatment includes medication for depression or other disorders, counseling by experts and sharing of experience with other addicts.
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 peers 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.
Types of treatment
The
brain’s chemical structure is impacted by drugs of abuse and these
changes are present long after an individual stops using. This change in
brain structure increases the risk of relapse, making treatment an
important part of the rehabilitation process.
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, 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)
measuring the treatment provider's responses on the Spiritual Belief
Scale (a scale measuring belief in the four spiritual characteristics Alcoholics Anonymous 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).
Scientific research since 1970 shows that effective treatment
addresses the multiple needs of the patient rather than treating
addiction alone. In addition, medically assisted drug detoxification or alcohol detoxification alone is ineffective as a treatment for addiction. 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. 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.
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.
- Motivational incentives, which uses positive reinforcement to encourage abstinence from the addictive substance.
- EEG Biofeedback augmented treatment improves abstinence rates of 12-step, faith-based and medically assisted addiction for cocaine, methamphetamine, alcoholism and opioid addictions.
Treatment can be a long process and the duration is dependent upon the
patient’s needs and history of abuse. Research has shown that most
patients need at least three months of treatment and longer duration's
are associated with better outcomes.
Medications
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.
All available studies collected in the 2005 Australian National
Evaluation of Pharmacotherapies for Opioid Dependence suggest that
maintenance treatment is preferable, with very high rates (79–100%) of relapse within three months of detoxification from levo-α-acetylmethadol (LAAM), buprenorphine, and methadone.
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. It is usually prescribed in outpatient
medical conditions. Naltrexone blocks the euphoric effects of alcohol
and opiates. Naltrexone cuts relapse risk during the first three months
by about 36%.
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).
Ibogaine is a hallucinogenic
drug promoted by certain fringe groups to interrupt both physical
dependence and psychological craving to a broad range of drugs including
narcotics, stimulants, alcohol, and nicotine. To date, there have never
been any controlled studies showing it to be effective, and it is not
accepted as a treatment by physicians, pharmacists, or addictionologist.
There have also 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 from tend
to have little oversight, and range from motel rooms to one
moderately-sized rehabilitation center.
A few antidepressants have been proven to be helpful in the
context of smoking cessation/nicotine addiction, these medications
include bupropion and nortriptyline.
Bupropion inhibits the re-uptake of nor-epinephrine and dopamine and
has been FDA approved for smoking cessation, while nortriptyline is a
tricyclic antidepressant which has been used to aid in smoking cessation
it has not been FDA approved for this indication.
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, even months.
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.
Patients who wish to continue drinking or may be likely to relapse,
should not take disulfiram as it can result in the disulfiram-alcohol
reaction mentioned previously, which is very serious and can even be
fatal.
Nitrous oxide, also sometimes known as laughing gas, is a legally
available gas used for purposes that include anesthesia during certain
dental and surgical procedures, as well as food preparation and the
fueling of rocket and racing engines. Substance abusers also sometimes
use the gas as an inhalant. Like all other inhalants, it's popular
because it provides consciousness-altering effects while allowing users
to avoid some of the legal issues surrounding illicit or illegal drugs
of abuse. Abuse of nitrous oxide can produce significant short-term and
long-term damage to human health, including a form of oxygen starvation,
called hypoxia, brain damage, and a serious vitamin B12 deficiency that can lead to nerve damage.
Although dangerous and addictive in its own right, nitrous oxide
has been shown to be an effective treatment for a number of addictions.
Residential treatment
In-patient
residential treatment for alcohol abuse is usually quite expensive
without proper insurance. Most American programs follow a traditional
28–30 day program length. The length is based solely upon providers'
experience. During the 1940's, clients stayed about one week to get over
the physical changes, another week to understand the program, and
another week or two to become stable.
70% to 80% of American residential alcohol treatment programs provide
12-step support services. These include, but are not limited to AA, Narcotics Anonymous, Cocaine Anonymous and Al-Anon.
One recent study suggests the importance of family participation in
residential treatment patient retention, finding "increased program
completion rate for those with a family member or significant other
involved in a seven-day family program".
Experimental treatment
The Nature of Things, a CBC Television program by David Suzuki, explored an experimental drug treatment by Dr. Gabor Maté in which the substance Ayahuasca was used to treat addicts in Vancouver.
Recovery
The
definition of recovery remains divided and subjective in drug
rehabilitation, as there are no set standards for measuring recovery.
The Betty Ford Institute defined recovery as achieving complete
abstinence as well as personal well-being while other studies have considered "near abstinence" as a definition. The wide range of meanings has complicated the process of choosing rehabilitation programs.
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 great 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.
In some cases, individuals can be court ordered to drug rehabilitation by the state through legislation like the Marchman Act.
Counseling
Traditional addiction treatment is based primarily on counseling.
Counselors help individuals with 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. Counselors 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 also work with family members who are affected by the addictions
of the individual, or in a community 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.
Counseling is also related to "Intervention"; a process in which the
addict's family and loved ones request help from a professional to get
an individual into drug treatment.
This process begins with a professionals' first goal: 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, instead of
continuing the destructive behavior. Once this has been achieved, the
counselor coordinates with the addict's family to support them on
getting the individual to 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 the 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.
Twelve-step programs
The disease model of addiction
has long contended the maladaptive patterns of alcohol and substance
use displays 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
being 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.
These approaches have met considerable amounts of criticism, coming
from opponents who disapprove of the spiritual-religious orientation on
both psychological and legal grounds. Opponents also contend that it lacks valid scientific evidence for claims of efficacy. However, there is survey-based research that suggests there is a correlation between attendance and alcohol sobriety.
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.
SMART Recovery
SMART Recovery was founded by Joe Gerstein in 1994 by basing REBT
as a foundation. It gives importance to the human agency in overcoming
addiction and focuses on self-empowerment and self-reliance. It does not subscribe to disease theory and powerlessness.
The group meetings involve open discussions, questioning decisions and
forming corrective measures through assertive exercises. It does not
involve a lifetime membership concept, but people can opt to attend
meetings, and choose not to after gaining recovery. Objectives of the
SMART Recovery programs are:
- Building and Maintaining Motivation,
- Coping with Urges,
- Managing Thoughts, Feelings, and Behaviors,
- Living a Balanced Life.
This is considered to be similar to other self-help groups who work within mutual aid concepts.
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 but not limited to alcohol abuse. To this end, a 1957 study
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 the 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.
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.
Psychoanalysis
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 hypothesized 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 hypothesized to be associated with life trajectories
that have occurred within the context of teratogenic processes, the
phases of which include social, cultural and political factors,
encapsulation, traumatophobia, and masturbation as a form of
self-soothing. 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 to 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.
Relapse prevention
An
influential cognitive-behavioral approach to addiction recovery and
therapy has been Alan Marlatt's (1985) Relapse Prevention approach. Marlatt describes four psycho-social processes relevant to the addiction and relapse processes: self-efficacy,
outcome expectancy, 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
expectancy 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 a 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
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.
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 dysfunctional. As with
any cognitive-behavioral therapy, homework assignments and behavioral exercises serve to solidify what is learned and discussed during treatment.
Emotion regulation and mindfulness
A growing literature is demonstrating the importance of emotion regulation
in the treatment of substance abuse. Considering that nicotine and
other psychoactive substances such as cocaine activate similar
psycho-pharmacological pathways,
an emotion regulation approach may be applicable to a wide array of
substance 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. Acceptance and commitment therapy (ACT), is showing evidence that it is effective in treating substance abuse, including the treatment of poly-substance abuse and cigarette smoking. Mindfulness
programs that encourage patients to be aware of their own experiences
in the present moment and of emotions that arise from thoughts, appear
to prevent impulsive/compulsive responses.
Research also indicates that mindfulness programs can reduce the
consumption of substances such as alcohol, cocaine, amphetamines,
marijuana, cigarettes and opiates.
Dual diagnosis
For example, someone with bipolar disorder that suffers from alcoholism would have dual diagnosis
(manic depression + alcoholism). In such occasions, two treatment plans
are needed with the mental health disorder requiring treatment first.
According to the National Survey on Drug Use and Health (NSDUH), 45
percent of people with addiction have a co-occurring mental health
disorder.
Behavioral models
Behavioral models make use of principles of functional analysis of
drinking behavior. Behavior models exist for both working with the
substance abuser (community reinforcement approach) and their family (community reinforcement approach 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/her addiction.
Criticism
Despite
ongoing efforts to combat addiction, there has been evidence of clinics
billing patients for treatments that may not guarantee their recovery.
This is a major problem as there are numerous claims of fraud in drug
rehabilitation centers, where these centers are billing insurance
companies for under delivering much needed medical treatment while
exhausting patients' insurance benefits. In California, there are
movements and laws regarding this matter, particularly the California
Insurance Fraud Prevention Act (IFPA) which declares it unlawful to
unknowingly conduct such businesses.
Under the Affordable Care Act and the Mental Health Parity Act,
rehabilitation centers are able to bill insurance companies for
substance abuse treatment. With long wait lists in limited state-funded rehabilitation centers, controversial private centers rapidly emerged.
One popular model, known as the Florida Model for rehabilitation
centers, is often criticized for fraudulent billing to insurance
companies.
Under the guise of helping patients with opioid addiction, these
centers would offer addicts free rent or up to $500 per month to stay in
their "sober homes", then charge insurance companies as high as $5,000
to $10,000 per test for simple urine tests.
Little attention is paid to patients in terms of addiction intervention
as these patients have often been known to continue drug use during
their stay in these centers. Since 2015, these centers have been under federal and state criminal investigation.
As of 2017 in California, there are only 16 investigators in the CA
Department of Health Care Services investigating over 2,000 licensed
rehab centers.
