Treatment for Substance Use Disorders, just like treatment for any chronic illness, has evolved over the years as our knowledge has increased. Through experience, research and improved technology we now know more about the progression of addiction, about brain chemistry and the effects of drugs on brain activity, and, through outcome studies, what actually works and what does not. We have seen the emergence of a whole new profession – the addiction counselor. We have seen the development of college degree programs focused on addiction studies. And we have seen this thing called “treatment” become big business.
No matter the treatment modality, there are four essential tasks, I believe, of any good treatment program:
1. Treatment should help reduce the stigma of addiction and offer hope of lasting recovery. I believe this is best done through an education process that helps addicts understand and accept the concept of addiction as a chronic illness, not so different from other chronic illnesses like diabetes or hypertension. This helps reduce the shame and self-loathing that most addicts feel as they reach that point of becoming willing to seek help.
2. Because addiction brings with it concurrent physical health, mental health, and social issues whose resolution is critical to recovery, treatment requires the integration and coordination of multiple services. This requires knowledge of community resources.
3. Long term recovery depends, in most cases, on involvement with and support from non-medical, non-professional community resources. Whether this support is through 12-Step groups, religious groups, or secular support groups – the key is acceptance of the fact that very few people recover from addiction on their own. A treatment program must introduce patients to some kind of ongoing support system.
4. Long term recovery depends on a psychic change – the development of acceptance, surrender, forgiveness, serenity – these are experiences of a spiritual nature. A treatment program has a responsibility, I believe, to address the importance of this kind of character change as essential to sustaining recovery and preventing relapse.
The level and quality of treatment an addict receives is often determined by the resources available. This might mean the availability of treatment programs within a certain geographic area and it might mean the financial resources available to pay for treatment. A few factors that might influence treatment options include health insurance or lack of it, support of one’s employer or lack of it, childcare issues, medical complications, and co-occurring mental illness just to name a few.
Listed here are the basic levels of care available in the treatment community. Everyone does not require treatment at every level, but many do.
The abuse of many substances creates a physical dependence that requires medical attention to safely withdraw from the drugs. This is most often done in a hospital setting under a doctor’s care and with 24-hour nursing care. It can sometimes be done in what is called a “social model” setting or on an outpatient basis under a doctor’s supervision of prescribed medication. The substances that most often require medical detoxification are alcohol, benzodiazepines, and opiate pain medications, including heroin.
Residential treatment is a “live-in” option that is what most people probably think of when they consider “rehab.” Residential treatment generally is from 30 to 90 days. It offers a safe environment, away from everyday stressors, where one can focus solely on their addiction recovery, get emotionally and physically stabilized, and be introduced to basic recovery concepts. Residential treatment varies greatly in terms of amenities and therapies offered, from “bare bones” to quite luxurious.
Outpatient treatment is designed for those who are somewhat more stabilized and have the ability to stay sober between sessions. It is a level of care designed for people who cannot take time away from work or family to go to residential treatment, often what are referred to as “functional” alcoholics or addicts. It is also used as a step-down from residential programs. Outpatient treatment is typically three to four 3-hour sessions weekly (Intensive Outpatient), but may also be five 6-hour sessions weekly (Partial Hospitalization). The benefits of outpatient treatment are extended length of stay and the practical application of recovery tools in a real life environment.
Sometimes called Aftercare, Continuing Care is a less structured environment designed to sustain recovery by continued involvement in either a group setting or individual therapy. The focus is on issues in early recovery and relapse prevention. This is often part of either a residential or outpatient program, or may also include individual therapy and community support groups like AA or NA.
An ideal treatment episode might include medical detoxification (if necessary) followed by residential treatment and a transition to outpatient treatment. The National Institute on Drug Abuse (NIDA) recommends a minimum of 90 days of treatment. Recent studies indicate that it often takes from one to one and a half years for the brain to heal, which coincides with old AA wisdom that recommends no major decisions in the first year of sobriety. The good news is that treatment works and that addiction is probably the most treatable illness there is.