Drug rehabilitation

Drug rehabilitation
ICD-9-CM 94.64

Drug rehabilitation (often drug rehab or just rehab) is the processes of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cocaine, heroin or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and cease substance abuse in order 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.[1]

Psychological dependency

Psychological dependency is addressed in many drug rehabilitation programs by attempting to teach the patient new methods of interacting in a drug-free environment. In particular, patients are generally encouraged, or possibly even required, to not associate with friends who still use the addictive substance. Twelve-step programs encourage addicts not only to stop using alcohol or other drugs, but to examine and change habits related to their addictions. Many programs emphasize that recovery is a permanent process without culmination. For legal drugs such as alcohol, complete abstention—rather than attempts at moderation, which may lead to relapse—is also emphasized ("One is too many, and a thousand is never enough.") Whether moderation is achievable by those with a history of abuse remains a controversial point, but is generally considered unsustainable. [2]

Types of treatment

Various types of programs offer help in drug rehabilitation, including: residential treatment (in-patient), out-patient, local support groups, extended care centers, recovery or sober houses, addiction counselling, mental health, 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 AA identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider's responses on the Addiction Belief Scale (a scale measuring adherence to the disease model or the free-will model addiction).[3]

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.[4] 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.[5]

Types of behavioral therapy include:

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.[8] All available studies collected in the 2005 Australian National Evaluation of Pharmacotherapies for Opioid Dependence suggest that maintenance treatment is preferable,[8] with very high rates (79–100%)[8] of relapse within three months of detoxification from LAAM, buprenorphine, and methadone.[8][9]

Ibogaine is a hallucinogenic drug promoted by certain fringe groups to interrupt both physical dependence and psychological craving to a broad range or drugs including narcotics, stimulants, alcohol and nicotine. To date, there have never been any controlled studies showing it to be effective, and it is accepted as a treatment by no association of physicians, pharmacists, or addictionologists. There have been several deaths related to ibogaine use, which causes tachycardia and long QT syndrome. The drug is an illegal Schedule I controlled substance in the United States, and the foreign facilities in which it is administered tend to have little oversight, and range from motel rooms to one moderately-sized rehabilitation center.[10] Some antidepressants also show usefulness in moderating drug use, particularly to nicotine, and it has become common for researchers to re-examine already approved drugs for new uses in drug rehabilitation.

According to the National Institute on Drug Abuse (NIDA), patients stabilized on adequate, sustained doses of methadone or buprenorphine can keep their jobs, avoid crime and violence, and reduce their exposure to HIV and Hepatitis C by stopping or reducing injection drug use and drug-related high risk sexual behavior. Naltrexone is a long-acting opioid antagonist with few side effects. It is usually prescribed in outpatient medical conditions. Naltrexone blocks the euphoric effects of alcohol and opiates. Naltrexone cuts relapse risk during the first 3 months by about 36%.[8] 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).[8]

Acamprosate, disulfiram and topiramate (a novel anticonvulsant sulphonated sugar) are also used to treat alcohol addiction. Acamprosate has shown effectiveness for patients with severe dependence, helping them to maintain abstinence for several weeks or months. 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.[11]

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.[12][13][14]

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 in the 1940s that clients needed about one week to get over the physical changes, another week to understand the program, and another week or two to become stable.[15] 70 to 80 percent of American residential alcohol treatment programs provide 12-step support services. These include, but are not limited to AA, NA, CA, Al-Anon[15]

Experimental treatment

The Nature of Things, a CBC Television program by David Suzuki, explored an experimental drug treatment by Dr. Gabor Maté who works with addicts in Vancouver which uses the substance Ayahuasca.[16]

Criminal justice

Drug rehabilitation is sometimes part of the criminal justice system. People convicted of minor drug offenses may be sentenced to rehabilitation instead of prison, and those convicted of driving while intoxicated are sometimes required to attend Alcoholics Anonymous meetings. There are a number of ways to address an alternative sentence in a drug possession or DUI case; increasingly, American courts are willing to explore outside-the-box methods for delivering this service. There have been lawsuits filed, and won, regarding the requirement of attending Alcoholics Anonymous and other twelve-step meetings as being inconsistent with the Establishment Clause of the First Amendment of the U. S. Constitution, mandating separation of church and state.[17][18]

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 identifying behaviors and problems related to their addiction. It can be done on an individual basis, but it's more common to find it in a group setting and can include crisis counseling, weekly or daily counseling, and drop-in counseling supports. They are trained to develop recovery programs that help to reestablish healthy behaviors and provide coping strategies whenever a situation of risk happens. It's very common to see them work also with family members who are affected by the addictions of the individual, or in a community in order to prevent addiction and educate the public. Counselors should be able to recognize how addiction affects the whole person and those around him or her.[19] Counseling is also related to "Intervention"; a process in which the addict's family requests help from a professional in order to get this person into drug treatment. This process begins with one of this professionals' first goals: breaking down denial of the person with the addiction. Denial implies lack of willingness from the patients or fear to confront the true nature of the addiction and to take any action to improve their lives, besides of continuing the destructive behavior. Once this has been achieved, professional coordinates with the addict's family to support them on getting this family member to alcohol drug rehabilitation immediately, with concern and care for this person. Otherwise, this person will be asked to leave and expect no support of any kind until going into drug rehabilitation or alcoholism treatment. An intervention can also be conducted in the workplace environment with colleagues instead of family.

One approach with limited applicability is the Sober Coach. In this approach, the client is serviced by provider(s) in his or her home and workplace — for any efficacy, around-the-clock — who functions much like a nanny to guide or control the patient's behavior.

Twelve-step programs

The disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displayed by addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. This conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness are unable to fight the disease by themselves without medication. Behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network who can help them remain sober. Such approaches are the quintessential features of Twelve-step programs, originally published in the book Alcoholics Anonymous in 1939.[20] These approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological[21] and legal[22] grounds. Nonetheless, despite this criticism, outcome studies have revealed that affiliation with twelve-step programs predicts abstinence success at 1-year follow-up for alcoholism. Different results have been reached for other drugs, with the twelve steps being less beneficial for addicts to illicit substances, and least beneficial to those addicted to the physiologically and psychologically addicting opioids, for which maintenance therapies are the gold standard of care.[23]

Client-centered approaches

In his influential book, Client-Centered Therapy, in which he presented the client-centered approach to therapeutic change, psychologist Carl Rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. Rogers believed the presence of these three items in the therapeutic relationship could help an individual overcome any troublesome issue, including alcohol abuse. To this end, a 1957 study[24] compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. Though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in outcome. Surprisingly, client-centered therapy proved most effective. It has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques per se.[25] 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.[26]

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 hypothesised specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesised to be associated with life trajectories that have occurred within the context of traumatogenic processes, the phases of which include social, cultural and political factors, encapsulation, traumatophilia, and masturbation as a form of self-soothing.[27] Such an approach lies in stark contrast to the approaches of social cognitive theory to addiction—and indeed, to behavior in general—which holds human beings regulate and control their own environmental and cognitive environments, and are not merely driven by internal, driving impulses. Additionally, homosexual content is not implicated as a necessary feature in addiction.

Relapse prevention

An influential cognitive-behavioral approach to addiction recovery and therapy has been Alan Marlatt's (1985) Relapse Prevention approach.[28] Marlatt describes four psychosocial processes relevant to the addiction and relapse processes: self-efficacy, outcome expectancies, attributions of causality, and decision-making processes. Self-efficacy refers to one's ability to deal competently and effectively with high-risk, relapse-provoking situations. Outcome expectancies refer to an individual's expectations about the psychoactive effects of an addictive substance. Attributions of causality refer to an individual's pattern of beliefs that relapse to drug use is a result of internal, or rather external, transient causes (e.g., allowing oneself to make exceptions when faced with what are judged to be unusual circumstances). Finally, decision-making processes are implicated in the relapse process as well. Substance use is the result of multiple decisions whose collective effects result in consumption of the intoxicant. Furthermore, Marlatt stresses some decisions—referred to as apparently irrelevant decisions—may seem inconsequential to relapse, but may actually have downstream implications that place the user in a high-risk situation.

For example: As a result of heavy traffic, a recovering alcoholic may decide one afternoon to exit the highway and travel on side roads. This will result in the creation of a high-risk situation when he realizes he is inadvertently driving by his old favorite bar. If this individual is able to employ successful coping strategies, such as distracting himself from his cravings by turning on his favorite music, then he will avoid the relapse risk (PATH 1) and heighten his efficacy for future abstinence. If, however, he lacks coping mechanisms—for instance, he may begin ruminating on his cravings (PATH 2)—then his efficacy for abstinence will decrease, his expectations of positive outcomes will increase, and he may experience a lapse—an isolated return to substance intoxication. So doing results in what Marlatt refers to as the Abstinence Violation Effect, characterized by guilt for having gotten intoxicated and low efficacy for future abstinence in similar tempting situations. This is a dangerous pathway, Marlatt proposes, to full-blown relapse.

Cognitive therapy

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.[29] This therapy rests upon the assumption addicted individuals possess core beliefs, often not accessible to immediate consciousness (unless the patient is also depressed). These core beliefs, such as "I am undesirable," activate a system of addictive beliefs that result in imagined anticipatory benefits of substance use and, consequentially, craving. Once craving has been activated, permissive beliefs ("I can handle getting high just this one more time") are facilitated. Once a permissive set of beliefs have been activated, then the individual will activate drug-seeking and drug-ingesting behaviors. The cognitive therapist's job is to uncover this underlying system of beliefs, analyze it with the patient, and thereby demonstrate its dysfunctionality. As with any cognitive-behavioral therapy, homework assignments and behavioral exercises serve to solidify what is learned and discussed during treatment.[30]

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 psychopharmacological pathways,[31] 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.[32] 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.[33][34] 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.[32][35] Research also indicates that mindfulness programs can reduce the consumption of substances such as alcohol, cocaine, amphetamines, marijuana, cigarettes and opiates.[35][36][37]

Behavioral models

Behavioral models make use of principles of functional analysis of drinking behavior. Behavior models exists for both working with the substance abuser (Community Reinforcement Approach) and their family (Community Reinforcement 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 addiction.

See also

References

  1. ↑ Potenza, M. N (12 October 2008). "The neurobiology of pathological gambling and drug addiction: an overview and new findings". Philosophical Transactions of the Royal Society B: Biological Sciences. 363 (1507): 3181–3189. PMC 2607329 Freely accessible. PMID 18640909. doi:10.1098/rstb.2008.0100.
  2. ↑ Marlatt, G, Alan (2005). Relapse Prevention. New York, New York: The Guilford Press. p. 81. ISBN 1-59385-176-6.
  3. ↑ Schaler, Jeffrey Alfred (1997). "Addiction Beliefs of Treatment michael vick Providers: Factors Explaining Variance". Addiction Research & Theory. 4 (4): 367–384. ISSN 1476-7392. doi:10.3109/16066359709002970.
  4. ↑ NIDA InfoFacts: Treatments Approaches for Drug Addiction National Institute on Drug Abuse (NIDA). Retrieved on 2010-08-17
  5. ↑ Principles of Drug Addiction Treatment National Institute on Drug Abuse (NIDA)>
  6. ↑ "Motivational Interviewing". SAMHSA.
  7. ↑ Stitzer ML, Petry NM, Peirce J. "Motivational incentives research in the National Drug Abuse Treatment Clinical Trials Network.". Johns Hopkins University School of Medicine Mid Atlantic Node. 38 Suppl 1: S61–9. PMC 2866424 Freely accessible. PMID 20307797. doi:10.1016/j.jsat.2009.12.010.
  8. 1 2 3 4 5 6 Mattick RP; Digiusto E; Doran CM; O'Brien S; Shanahan M; Kimber J; Henderson N; Breen C; Shearer J; Gates J; Shakeshaft A; NEPOD Trial Investigators (2004). National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of Results and Recommendations (PDF). National Drug and Alcohol Research Centre, Sydney. Commonwealth of Australia. ISBN 0-642-82459-2. Monograph Series No. 52. Archived from the original (PDF) on 2011-03-09.
  9. ↑ "National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) Report of Results and Recommendations". Archived from the original on 6 March 2016.
  10. ↑ K.R. Alper; H.S. Lotsof; C.D. Kaplan (2008). "The Ibogaine Medical Subculture". J. Ethnopharmacology. 115 (1): 9–24. PMID 18029124. doi:10.1016/j.jep.2007.08.034. Archived from the original on 2008-02-06. Retrieved 2010-10-05.
  11. ↑ Pharmacotherapies National Institute on Drug Abuse (NIDA). Retrieved on 2010-08-17
  12. ↑ Daynes, G; Gillman MA (1994). "Psychotropic analgesic nitrous oxide prevents craving after withdrawal from alcohol, cannabis and tobacco". Int J Neurosci. 76 (1-2): 13–16. doi:10.3109/00207459408985987.
  13. ↑ Gillman MA (1994). "Analgesic nitrous oxide for addictive withdrawal". S Afr Med J. 84: 516.
  14. ↑ "South African Brain Research Institute".
  15. 1 2 Glaser, Gabrielle. "The Bad Science of Alcoholics Anonymous". The Atlantic. Retrieved 2016-02-29.
  16. ↑ "Jungle Prescription". The Nature of Things. 10 November 2011. CBC-TV.
  17. ↑ Egelko, Bob (2007-09-08). "Appeals court says requirement to attend AA unconstitutional". San Francisco Chronicle. Retrieved 2007-10-08.
  18. ↑ "United States Court of Appeals for the Ninth Circuit" (PDF).
  19. ↑ Counselors United States Department of Labor. Retrieved on 2010-08-17
  20. ↑ Alcoholics Anonymous (June 2001). Alcoholics Anonymous (4th ed.). Alcoholics Anonymous World Services. ISBN 1-893007-16-2. OCLC 32014950.
  21. ↑ Bandura, A. (1999). "A sociocognitive analysis of substance abuse: An agentic perspective". Psychological Science. 10 (3): 214–7. doi:10.1111/1467-9280.00138.
  22. ↑ Wood, Ron (December 7, 2006). Suit challenges court ordered 12-step programs: Constitutionality of forced participation in program questioned. The Morning News. Retrieved 2008-5-22.
  23. ↑ Moos RH, Finney JW, Ouimette PC, Suchinsky RT (March 1999). "A comparative evaluation of substance abuse treatment: I. Treatment orientation, amount of care, and 1-year outcomes". Alcohol. Clin. Exp. Res. 23 (3): 529–36. PMID 10195829. doi:10.1111/j.1530-0277.1999.tb04149.x.
  24. ↑ Ends EJ, Page CW (June 1957). "A study of three types of group psychotherapy with hospitalized male inebriates". Q J Stud Alcohol. 18 (2): 263–77. PMID 13441877.
  25. ↑ Cartwright AK (December 1981). "Are different therapeutic perspectives important in the treatment of alcoholism?". Br J Addict. 76 (4): 347–61. PMID 6947809. doi:10.1111/j.1360-0443.1981.tb03232.x.
  26. ↑ Division of Behavioral Health Services, ADHS/DBHS Best Practice Advisory Committee. "Client Directed, Outcome Informed Practice (CDOI)".
  27. ↑ Hopper E (December 1995). "A psychoanalytical theory of 'drug addiction': unconscious fantasies of homosexuality, compulsions and masturbation within the context of traumatogenic processes". Int J Psychoanal. 76 (Pt 6): 1121–42. PMID 8789164.
  28. ↑ Marlatt, G. Alan (1985). "Cognitive factors in the relapse process". In Gordon, Judith R.; Marlatt, G. Alan. Relapse prevention: maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press. ISBN 0-89862-009-0.
  29. ↑ Beck, Aaron T.; Wright, Fred D.; Newman, Cory F.; Liese, Bruce S. (16 January 2001). "Ch 11: Focus on Beliefs". Cognitive Therapy of Substance Abuse. Guilford Press. pp. 169–186. ISBN 978-1-57230-659-2.
  30. ↑ "Addiction & Alcohol Rehab, Alcohol Detox, Drug Rehabilitation In Peterborough, UK.". Addiction Rehab Peterborough. Retrieved 10 November 2016.
  31. ↑ Mendelson JH, Sholar MB, Goletiani N, Siegel AJ, Mello NK (September 2005). "Effects of low- and high-nicotine cigarette smoking on mood states and the HPA axis in men". Neuropsychopharmacology. 30 (9): 1751–63. PMC 1383570 Freely accessible. PMID 15870834. doi:10.1038/sj.npp.1300753.
  32. 1 2 Carmody TP, Vieten C, Astin JA (December 2007). "Negative affect, emotional acceptance, and smoking cessation". J Psychoactive Drugs. 39 (4): 499–508. PMID 18303707. doi:10.1080/02791072.2007.10399889.
  33. ↑ Ruiz, F. J. (2010). "A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies". International Journal of Psychology and Psychological Therapy. 10 (1): 125–62.
  34. ↑ Hayes, Steven. "State of the ACT Evidence". ContextualPsychology.org.
  35. 1 2 Black DS (Apr 2014). "Mindfulness-based interventions: an antidote to suffering in the context of substance use, misuse, and addiction". Subst Use Misuse. 49 (5): 487–91. PMID 24611846. doi:10.3109/10826084.2014.860749.
  36. ↑ Chiesa A (Apr 2014). "Are mindfulness-based interventions effective for substance use disorders? A systematic review of the evidence". Subst Use Misuse. 49 (5): 492–512. PMID 23461667. doi:10.3109/10826084.2013.770027.
  37. ↑ Garland EL (Jan 2014). "Mindfulness training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface". Front Psychiatry. 4 (173). doi:10.3389/fpsyt.2013.00173.
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