Scientific research since the mid-1970s shows that treatment can help patients addicted to drugs stop using, avoid relapse, and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment programs:
- No single treatment is appropriate for everyone.
- Treatment needs to be readily available.
- Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
- Remaining in treatment for an adequate period of time is critical.
- Counselling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment.
- Medications are an important element of treatment for many patients, especially when combined with counselling and other behavioral therapies.
- An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
- Many drug–addicted individuals also have other mental health disorders.
- Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long–term drug abuse
- Treatment does not need to be voluntary to be effective.
- Drug use during treatment must be monitored continuously, as lapses during treatment can and do occur.
- Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk–reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.
Medications can be used to help re-establish normal brain function and to prevent relapse and diminish cravings. Currently, we have medications for opioids, tobacco, and alcohol addiction and are developing others for treating stimulant (cocaine, methamphetamine) and cannabis addiction. Most people with severe addiction problems, however, are poly-drug users (users of more than one drug) and will require treatment for all of the substances that they abuse.
- Opioids: Methadone, Suboxone and, for some individuals, Naltrexone are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and Suboxone suppress withdrawal symptoms and relieve cravings. All medications help patients disengage from drug seeking and related criminal behavior and become more receptive to behavioral treatments. Buprenorphine/Naloxone should be considered first line therapy for opiate dependency.
- Alcohol: Three medications have been FDA–approved for treating alcohol dependence: Naltrexone, Acamprosate, and Disulfiram. A fourth, Topiramate, is showing encouraging results in clinical trials. In addition to these, high dose Baclofen and Gabapentin can help patients abstain from alcohol. Naltrexone using the Sinclair Method has been useful for calming the reward pathway in patients who drink alcoholically.
Opioids include drugs such as oxycodone, morphine, codeine, hydromorphone, fentanyl and heroin. Possible treatment options for opioid drugs include withdrawal management with referral to residential treatment, opiate agonist therapy, and opioid antagonist medications such as Naltrexone. If opioid use continues with any of these options, the treatment approach should be intensified.
Medications may offer help in suppressing withdrawal symptoms during detoxification. However, medically assisted detoxification is not in itself “treatment” – it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated – if they use drugs intravenously, they are high risk for overdose as well as needle-borne illnesses such as Hepatitis C and HIV.
Unfortunately, withdrawal management lacks effectiveness for long term sobriety and often rapidly leads to high rates of relapse post withdrawal treatment. Individuals receiving only inpatient opioid withdrawal management are at increased risk of fatality from drug overdose compared with those who receive no treatment at all. Withdrawal management alone is therefore not recommended unless there is a strategy for ongoing intensive outpatient monitoring or residential treatment. Take home Naloxone should be considered for those leaving detox, residential treatment or incarceration to prevent fatal overdoses.
Opiate Agonist Treatment
Opioid agonist maintenance treatment uses buprenorphine/Naloxone (Suboxone) and Methadone to reduce cravings and physically stabilize patients during the recovery process and they have been shown to be superior to withdrawal management in terms of retention in treatment, sustained abstinence from opioid use, and reduced risk of morbidity (e.g., HIV and Hep C transmission) and premature death. They are considered the “Gold Standard” and expected standard of care for opioid dependency. The choice of agonist treatment depends on several patient-specific factors such as initial presentation, other medical problems, patient preference, and response to treatment. Regardless of type of treatment administered, agonist maintenance treatment should incorporate long-term addiction monitoring, including regular follow up with a physician, urine drug screens, mental health care, counselling (including self-help groups) and treatment of other co-existing medical problems such as Hepatitis.
Relapse has been shown to be relatively common– up to 80% – amongst patients who attended inpatient residential treatment for opioids, of which 56% occur within the first week after discharge from the program. This is not because residential treatment is ineffective for opiate dependency, but because the withdrawal, including post-acute withdrawal which can happens weeks or months later, is extremely difficult for patients. This is why Opiate Agonist treatment is considered the most effective treatment for opioid use disorder. Residential treatment should always be followed up by a good after care program, including self-help groups.
Alcohol dependence is a chronic, relapsing disorder marked by compulsive alcohol use, an inability to stop drinking despite harmful consequences, and the emergence of withdrawal symptoms when patients quit drinking. Quitting drinking involves symptoms of craving, significant anxiety, depressed mood, and sleep disturbance, all of which have been identified as risk factors for relapse.
Alcohol withdrawal is often an uncomfortable, even painful process that takes both time and tenacity to get past. Abrupt discontinuation of alcohol consumption can lead to “shakes” in the morning, hallucinations, and seizures. Alcohol withdrawal can be fatal if it leads to delirium tremens. The physical cravings for alcohol – combined with its powerful psychological effects – often drive people right back to drinking. Fortunately, some medications have demonstrated the ability to help make the alcohol withdrawal process more tolerable as well as reduce the risk of seizures. Medications should always be used in conjunction with counselling and attendance at AA or SMART Recovery meetings.