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Requirements for Effective Treatment

Most people with substance use disorder recover. They recover despite our chronically underfunded treatment services for addiction and other mental health disorders, not because of them. Even more will recover once we have publicly-funded, timely, compassionate, evidence-based treatment for all. There is great reason for hope as there is new awareness that our system requires significant change and that this change is required as soon as possible. As the stigma of addiction and other mental health disorders lifts, more people will seek treatment earlier, providing a faster road to recovery. If there is life, it is never too late to recover.

It is important for family members to have realistic expectations about recovery. People still often view addiction as an acute illness, but it is a chronic disease. It needs to be managed over time, like other chronic illnesses. Although it is possible, it is unusual for a person to enter recovery and never relapse.

“Numerous studies have shown that, on average, people reach sustained abstinence only after three to four episodes of different kinds of treatment over a number of years…The good news is that, even though many people with serious drug and alcohol disorders require multiple episodes of treatment before they reach at least a year of sobriety, a 2012 review of scientific studies for SAMHSA by William White revealed that, on average, about half of adults who received professional treatment did achieve recovery. (In the many fewer adolescent studies, the recovery rate was 35%.)”
Inside Rehab –  Anne Fletcher (p. 340-341)

Principles of Drug Addiction Treatment: A Research-Based Guide by The National Institute on Drug Abuse (NIDA) is an excellent resource for families. According to NIDA, treatment does not have to be entered into voluntarily in order for it to be effective. However, there are many requirements for treatment to be effective:

Immediately Available

Substance use disorder (SUD) is a progressive disease. This means that if it is left untreated it tends to get worse over time.  The sooner someone begins recovery, the better the outcome. Persons in active addiction often do things they would never do otherwise and this creates negative social consequences that make many aspects of their lives (relationships, employment, education and finances) much worse. If they don’t have post-traumatic stress disorder (PTSD) when their addiction begins, they may have it before it ends. In other words, their experiences in active addiction can add to the work that must be done in recovery.

The majority of people with SUD at any given time do not seek treatment. That is another reason it is so important that they receive help as soon as they decide that they need it. Where the drugs being used are illegal and can be laced with anything, the next use could be fatal. A wait list can be a death sentence.

Continuum of Care

Addiction is a chronic illness that should be managed over a lifetime just as other chronic illnesses like diabetes or hypertension are managed.  In the case of mild SUD, it is possible that a brief intervention with counselling to develop coping skills is all that will be required. At the severe end of addiction, it is likely that treatment will involve detox to manage withdrawal, residential treatment, outpatient treatment while in a sober home, and ultimately reintegration into the community with ongoing supervision by professionals of medications and involvement with self-help groups.

Detox

Often persons in recovery need to start with detox. Detox is the period of time during which a person is in withdrawal. Medically supervised detox is important when someone is detoxing from alcohol or benzodiazepines as stopping either of these drugs cold turkey can be fatal. Detox is simply the first step towards recovery. On its own, detox is rarely sufficient to maintain recovery.

Here are average periods of withdrawal for various drugs:

Drug Withdrawal Period
Alcohol 5-7 days
Cannabis Up to two weeks
Cocaine 2-3 days
Opioids 1-4 weeks
Amphetamines/Methamphetamines 2-10 days
Tobacco 2 days – 2 weeks
Benzodiazepines 10-14 days

Depending on the length of use and delivery system (swallowing, snorting, smoking or injecting) detox may even be contraindicated with respect to opioid use disorder. Patients who are detoxed from opioids usually have withdrawal with very distressing symptoms – anxiety, depression, craving, insomnia.  But they lose tolerance to opioids within days of abstinence. So if they relapse (and most of them do) then they are at high risk for overdose.  Medication Assisted Treatment (MAT) prevents this. Those with a severe addiction to opioids may be best to start with MAT for a significant period of time (called maintenance) before tapering off the medication. In the most severe cases a person may not be able to safely taper off the medication.

While some people in recovery believe that withdrawal is the most difficult part of recovery, others say that staying off drugs and dealing with cravings after detox is the hardest part.

Duration

The length of treatment required, whether residential treatment or outpatient, depends on the severity and duration of a person’s addiction and co-occurring mental health disorders. As a rule of thumb, most persons will require a minimum of three months of treatment. Further, longer treatment periods are associated with better treatment outcomes.

SUD is a chronic disease. People in recovery need time to learn how to manage their condition. Similarly, family members need to learn how to manage their expectations. A few relapses are to be expected.  While a relapse is certainly cause for concern, consider focusing on the time your loved one has been in recovery instead of the times they have relapsed.

Customized

There is no one size fits all solution for substance use disorder. The treatment required for each person is as unique as that individual and their experiences, temperament, genetics, co-occurring mental health disorders, and drug of choice.

Social Issues

People starting recovery have often led chaotic lives. They may be homeless, jobless, and have legal problems. It is important to assist them with all of these issues to overcome stress and feelings of hopelessness. “Housing First” is a program that has been piloted in many locations, including Canada, and has had good success. The evidence is that people struggling with addiction and other mental health disorders are in a better position to recover if they have support and somewhere to live. This allows them to focus on the work of recovery rather than having to deal with the stress of living on the streets.

Co-occurring Mental Health Disorders

Persons entering recovery should be screened for other mental health disorders. Heavy and chronic use of some drugs (like marijuana, alcohol, methamphetamine and phencyclidine (PCP) can result in a temporary psychosis that can last for months or years if a person continues to use and does not receive treatment. Marijuana can trigger schizophrenia in genetically predisposed persons. If a person has anxiety or depression and concurrent problematic substance use, a psychiatrist can’t immediately make a definitive diagnosis as to whether the mood disorder is primary or secondary. Short treatment programs of 21 to 28 days are not sufficiently long to assess and address co-occurring disorders unless it is clear that these disorders preceded the struggle with addiction.

It is widely accepted that SUD and co-occurring mental health disorders should be treated at the same time. Addressing the addiction without addressing the concurrent mental health disorders, or vice versa, is generally not effective. However, concurrent treatment is often difficult to receive. Mental health and addictions have historically been separated in our health care system and these silos still exist.

Infectious Diseases

Persons starting recovery should be screened for infectious diseases such as Hepatitis B and C, HIV/Aids and sexually transmitted diseases.

Counselling

Generally individual, group and family therapy are all part of treatment with group therapy being the therapy which is most frequently used. Various behavioral therapies may be used such as cognitive behavioral therapy, dialectical behavioral therapy, contingency management and motivational interviewing. These therapies address the underlying reasons that people use substances to cope with life and help them develop effective coping skills. Since this involves not just stopping old habits but developing new habits, it takes time. Counselling and medication assisted treatment (MAT) are the two core components to treatment.

Medication

Medication Assisted Treatment (MAT) is when medications are used to help minimize the pain of withdrawal from substances and to deal with cravings. These medications have been approved for alcohol, nicotine and opioids (like oxycodone, morphine, fentanyl, methadone or heroin). For other drugs like marijuana and stimulants like cocaine, no medications have yet been approved but they are being researched. MAT is discussed in greater detail here.

Special Consideration for Adolescents

Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide by The National Institute on Drug Abuse (NIDA) is an excellent resource for families. The principles of effective treatment for adolescents are very similar to that for adults. The most significant differences include:

  • Early intervention is even more critical for adolescents because their brains are still developing and are particularly susceptible to developing substance use disorder. Just as dementia is a disease of the elderly, addiction is a disease of adolescence.
  • It is not uncommon for an adolescent struggling with addiction to have a history of physical, emotional or sexual abuse or to have suffered some other form of trauma. These youth may need protection from some of the adults in their lives.
  • Family involvement and family therapy is even more important for adolescents, especially if there is a hope that the adolescent will return home after treatment. Addiction is a disease that affects everyone in the family. Everyone needs to learn better coping skills.
  • Finally, medications used in medication assisted treatment (MAT) generally have not been researched on adolescents. There is a belief that they work just as well for adolescents. However, because youth in treatment may not have struggled for as long or as severely as adults, they may not need MAT or may need less intensive medications and for shorter durations than adults.

FAR would like to thank Dr. Meldon Kahan for reviewing the Requirements for Effective Treatment section of this website for accuracy.