The treatment of alcoholism and drug addiction is undergoing revolutionary change after decades of status quo. Changes in treatment approaches are being spearheaded by reports and recommendations from organizations such as the Institute of Medicine, the Institutes of Health and the National Quality Forum. A few of these changes are highlighted in this article.
First is the use of evidence-based practices, which extensive research has proven to be the most effective in combating addictions. The gap between the establishment of a treatment approach as efficacious and the adoption of the practice in treatment organizations is an amazing 17 years. Many of the dominant treatment approaches were developed in the 1950s and ‘60s based on beliefs, personal experience and folklore, rather than science. It is not being said that the historical substance abuse treatments are ineffective—most of us know persons who have benefited greatly. Yet few people would say, “I want the same cancer treatment my grandfather received in 1955.”
The issue is using practices that have been proven to make treatment more effective. The good news is that efforts from organizations such as the National Institutes of Alcoholism and Alcohol Abuse, the National Institute of Drug Abuse, and the Substance Abuse and Mental Health Services Administration are underway to bring evidence-based treatments into standard practice.
More Effective Medications
Research funded by the National Institutes of Health is also clearly identifying the specific mechanisms through which alcohol and other drugs work within the chemical functioning in the brain. While alcoholism and addiction have been metaphorically classified as a disease for many years, research is now establishing the scientific foundation for changes in brain functioning that result in a chronic disorder. This research establishes the foundation for developing drugs that can address various addictions.
Prior to 1994, there were only two FDA-approved medications for substance abuse treatment: Antabuse (disulfiram), approved in 1951, and Methadone, which received approval in the 1960s. Since 1992, five new addiction-treatment medications have received FDA approval. These include Subutex (buprenorphine) and Suboxone (buprenorphine and naloxone) for opiate treatment, and ReVia (naltrexone), Vivitrol (injectable naltrexone) and Campral (acamprosate) for alcoholism. Dozens of additional medications are in the process of research and development.
One of the five recommendations from the aforementioned national organizations is that these medications be utilized regularly. Hopefully, this advice will be heeded by the addiction treatment field. It would be difficult to imagine the primary healthcare system addressing hypertension or diabetes without offering effective medications that are available, and only offering talk-therapy and advice on lifestyle change to control these conditions. Yet, this is exactly what has been prevalent in substance abuse treatment.
Addiction as a Chronic Disorder
A third emerging movement is to operationalize the premise that alcoholism and drug addiction are chronic disorders. The chronic condition of these disorders is evidenced by the fact that the majority of people entering substance abuse treatment have experienced previous treatment episodes. The key word in the previous sentence is “episodes.” One does not usually have an episode of treatment for other chronic medical conditions such as diabetes, asthma or hypertension— treatment and monitoring for these disorders is ongoing.
Addiction treatment has historically utilized an acute model of care, similar to treating a broken bone. In an acute care approach, individuals are admitted, treated and discharged. The one bright side has been attempting to assist persons to establish an ongoing relationship with a mutual aid organization following treatment—this has predominately been a “12-step” group such as Alcoholics Anonymous. The treatment field has begun to recognize the need to abandon the acute care model in favor of a disease management approach which provides ongoing support and monitoring as well as early address if an individual returns to the use of alcohol or drugs.
A fourth, and long overdue, transformation is listening to the consumer and providing person-centered care. Addiction treatment has consisted of predetermined “programs,” usually in an inpatient or intensive outpatient setting in which persons seeking assistance must participate. The consumer voice had been absent from the process. Persons who do not comply with the offerings of a particular provider have often been labeled as unmotivated or “not having hit bottom.” Worse yet, many providers have discharged persons who did not immediately achieve absolute abstinence from all alcohol or drugs. One of the diagnostic criteria for dependency is the inability to refrain from use. People have actually been discharged for confirming their diagnosis.
Conversely, “person-centered” treatment involves the individual in making decisions on what his or her goals are and the best way for both individuals and their families to achieve these goals. The individual receives assistance in developing his or her personal recovery plan rather than having a treatment plan dictated by the program staff. For example, a person may choose to use a medication that treats alcoholism combined with individual counseling, and perhaps a specific counseling group to develop new skills needed to achieve his or her self-selected goals. The key is that the individual receiving the treatment is a partner and has an investment in the treatment outcome.
Treatment Works Better If…
A national slogan for the addiction field has been “treatment works.” We propose that treatment works better if:
- We assist persons to rapidly access treatment.
- Services are available and affordable.
- Services are welcoming and we assist persons to stay in treatment.
- We stop kicking people out of treatment.
- We provide an adequate dose of treatment.
- Evidence-based practices including medications are used and we continue to develop new technologies.
- We truly provide treatment that meets individual needs and goals.
- We empower people to use their inherent strengths and develop their own personal recovery plans.
- We integrate addiction treatment with mental health, primary care and other needed services.
- Treatment is followed by continuing care, active engagement with indigenous communities of recovery and needed recovery support services. iBi