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Treatment

Considering the time, effort and resources that are invested in an employee, treatment of substance use disorders can be a cost-effective alternative to job termination. Reported job problems including absenteeism, reduced worker productivity, mistakes, disagreements with supervisors and work-related injuries are cut by an average of 75% among employees who have received substance abuse disorder treatment.1 Treatment can arrest the progression of addiction -- a chronic, relapsing disorder characterized by the compulsive use of one or more substances, resulting in physical, psychological, or social harm to the individual as well as continued use of the substance(s) despite this harm. Treatment of these disorders is often covered under healthcare benefits and many workplaces can assist workers with accommodating a work schedule in order to get treatment and help that worker return to work after successful treatment. Health problems are also improved following treatment, with alcohol and drug-related medical visits declining by 53%.2

The American Society of Addiction Medicine (ASAM) defines drug addiction treatment as an application of planned procedures to identify and change patterns of behavior that are maladaptive, destructive, and/or injurious to health; or to restore appropriate levels of physical, psychological, and/or social functioning. Drug addiction treatment can include behavioral modification, medications, or a combination of both. In other words, treatment for drug addiction is a process of recognizing that a problem exists, getting off of the drug with help, having support to stop using the substance, and totally stopping substance use.

What are the basic goals of treatment?

According to the National Institute on Drug Abuse (NIDA), the ultimate goal of drug addiction treatment is for an individual to achieve lasting abstinence. However, the immediate goals are to reduce drug abuse, improve the person's ability to function, and minimize the medical and social complications of drug abuse and addiction.

What makes for good treatment?

The National Institute on Drug Abuse (NIDA) identifies 13 principles for effective drug addiction treatment. They are:

  1. Addiction is a complex treatable disease that affects brain function and behavior.
  2. No single treatment is appropriate for all individuals.
  3. Treatment needs to be readily available.
  4. Effective treatment attends to multiple needs of the individual, not just his or her drug use.
  5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
  6. Individual and/or group counseling and other behavioral therapies are the most commonly used forms of drug abuse treatment.
  7. Medications are often an important element of treatment, especially when combined with counseling and other behavioral therapies.
  8. An individual's treatment and services plan must be assessed continually and modified to ensure that it makes his or her changing needs.
  9. Individuals who have co-existing substance use and mental disorders should have both disorders treated in an integrated way.
  10. Medical detoxification is only the first stage of addiction treatment and does little to change long-term drug use.
  11. Treatment does not need to be voluntary to be effective.
  12. Possible drug use during treatment must be monitored continuously through some form of drug testing to help the individual withstand urges to use drugs and to provide early evidence of a lapse to drug use so that the treatment plan can be adjusted.
  13. Treatment programs should provide assessment for HIV/AIDS, Hepatitis B and C, Tuberculosis and other infectious diseases, and counseling to help individuals modify or change behaviors that place themselves or others at risk of infection.

In addition to these principles, it is important to remember that recovering from addiction is a long-term process and frequently requires multiple episodes of treatment.

What are the different kinds of treatment?

There is no one-size-fits-all treatment program. Ideally, treatment should be tailored to the specific needs of individuals and will vary by setting, duration, and intensity. An employee's health insurance benefits also need to be considered when looking at options for substance abuse treatment as those benefits may determine what type of treatment is available. While a number of different treatment settings exist, all have been shown to be effective in reducing drug use. There are two general types of treatment under which a variety of specific approaches exist. They are residential/inpatient and outpatient programs.

Residential or Inpatient refers to treatment that take place in one of a number of different settings such as a medical or general psychiatric setting or a specialized chemical dependency unit. Inpatient treatment offers several advantages over less intensive programs such as:

  • A high level of medical supervision is offered for individuals who require intensive physical and/or psychiatric monitoring.
  • The intensity may be helpful to clients who do not respond to lesser measures.
  • It may increase awareness of internal triggers that place individuals at risk of returning to drug abuse.
  • It can help to interrupt a cycle of drug use even in the absence of dangerous withdrawal symptoms.

Inpatient treatment can be either short-term or long-term. Short-term residential programs provide intensive but relatively brief residential treatment based on a modified 12-step (such as Alcoholics Anonymous) approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980's, a similar approach was applied to the treatment of addiction to illicit drugs. Once referred to as the 28-day model, this type of residential treatment program generally includes a medically-monitored inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as Alcoholics Anonymous. Inpatient treatment programs work with the needs of the individual and length of stay may vary from three weeks to six weeks, depending upon what is deemed medically appropriate. After completion of the intensive inpatient program, some employees may be able to return to the workplace while also attending a follow up support group. Reduced health care coverage for treatment of substance use disorders has resulted in a diminished number of these programs, and the average length of stay under managed care review is much shorter than in earlier programs.

Long-term residential treatment provides care 24 hours per day, generally in non-hospital settings. The best known residential treatment model is the therapeutic community (TC). TCs are residential programs with planned lengths of stay of 6 to 12 months and focus on the "re-socialization" of the individual through the use of the program's entire "community," including other residents, staff, and the social context, as active components of treatment. Research shows that TCs can be modified to treat individuals with special needs, including those with more severe problems and criminal involvement.

Outpatient programs provide rehabilitation of the addict in real-life settings. Outpatient drug-free treatment varies in the types and intensity of services offered. Such treatment often costs less than inpatient treatment and often is more suitable for individuals who are employed or who have extensive social supports. Low-intensity programs may offer little more than drug education. Other outpatient models, such as intensive day treatment or Community Reinforcement Approach (CRA) Plus Vouchers can be, can be comparable to residential programs in services and effectiveness, depending on the individual client's characteristics and needs and focus on maintaining abstinence long enough for patients to learn new life skills to help sustain it. In many outpatient programs, group counseling is emphasized. Some outpatient programs are designed to treat clients who have medical or mental health problems in addition to their drug disorder.

There are several elements of treatment that are common to both inpatient and outpatient settings.

Detoxification treats the acute physiological effects of stopping drug use by systematically withdrawing addicting drugs in an inpatient or outpatient setting, typically under the care of a physician. Detoxification is considered a precursor of treatment and can be done in inpatient or outpatient settings. It is not designed to address the psychological, social, and behavioral problems associated with addiction, and therefore, it does not typically produce lasting behavioral changes necessary for recovery.

Individualized Drug Counseling - This addiction treatment method focuses directly on reducing or stopping the addict's illicit drug use. It also addresses related areas of impaired functioning such as employment status, illegal activity, family/social relations as well as the content and structure of the client's recovery program. Through its emphasis on short-term behavioral goals, individualized drug counseling helps the individual develop coping strategies and tools for abstaining from drug use and then maintaining abstinence. The addiction counselor encourages 12-step participation and makes referrals for needed supplemental medical, psychiatric, employment, and other services. Individuals are encouraged to attend sessions one or two times per week.

Individualized drug counseling often consists of behavioral therapy. Behavioral treatments help engage clients in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviors related to drug abuse, and increase their life skills to handle stressful circumstances and environmental cues that may trigger intense cravings for drugs and prompt another cycle of compulsive behavior. Several behavioral therapies have been shown to be effective in addressing substance abuse and include cognitive-behavioral therapy (CBT); contingency management interventions/ motivational incentives; motivational enhancement therapy (MET) and the matrix model.

Group therapy -is led by a professional substance abuse and provides positive peer support, a reduction in the sense of isolation, real-life examples of people in recovery, and help from peers in coping with substance abuse and other life problems.

Behavioral Couples Therapy (BCT) - is a therapy for drug abusers with partners. BCT uses a sobriety/abstinence contract and behavioral principles to reinforce abstinence from drugs and alcohol and is often used in conjunction with individual and group therapy.

Self-Help Programs/12-Step Facilitation Therapy -Most drug addiction treatment programs encourage clients to participate in a self-help program during and after treatment to complement and extend the effects of professional treatment. Twelve-step facilitation therapy is an active engagement strategy designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups and promote abstinence. The most prominent self-help groups are those affiliated with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA).

Relapse prevention - Relapse prevention is a systematic method of teaching recovering clients to recognize and manage relapse warning signs. It consists of a collection of strategies intended to enhance self-control and includes exploring the positive and negative consequences of continued substance use, self-monitoring to recognize drug cravings early on and to identify high-risk situations for use, and developing strategies for coping with and avoiding high-risk situations and the desire to use. Some workplaces, through an Employee Assistance Program, offer relapse prevention groups at the worksite as part of follow up in addiction treatment.

Education - In addition to the drug-related physical and psychological issues that must be addressed during treatment, individuals typically need to prepare for life beyond drug use. Research has shown a positive correlation between education, such as pursuing a high school diploma or GED or taking college-level courses, and a drug-free lifestyle after treatment.

Life skills - As with education, some individuals need to learn or relearn basic life skills. Treatment programs will often incorporate lessons on opening a bank account, going food shopping, personal hygiene, and keeping a clean house into their treatment regimen.

Employment-related skills - Employment is a key factor in maintaining long-term sobriety. Treatment programs realize recovering drug abusers either need to return to their previous place of work or find new employment if they are to be successful in their efforts to abstain from drug use. While workforce development is easier for individuals with certain skills, recovering addicts often need to start fresh. A critical component of drug treatment is providing the necessary skills so that employment can be obtained after treatment is completed.

Are medications available for treatment?

Yes. Medications can be used to help with different aspects of the treatment process. They offer help in suppressing withdrawal symptoms during detoxification. They can also be used to help re-establish normal brain function and to prevent relapse and diminish cravings throughout the treatment process. Currently, there are medications for opioid (heroin, morphine) and tobacco (nicotine) and alcohol addiction, and, according to NIDA, others are being developed for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. Methadone and buprenorphine and naltrexone are used for opiate addiction. Methadone prevents opiate withdrawal, blocks the effects of illicit opiate use, and decreases opiate craving. Buprenorphine prevents withdrawal symptoms when someone stops taking opioid drugs by producing similar effects to these drugs. Naltrexone prevents an addicted individual from feeling the effects associated with opiod use, blocks all the effects of illicit opiate use and works best when combined with behavioral treatment. Methadone treatment has been evaluated more rigorously than any other drug abuse treatment alternative and has been shown to be highly effective in retaining a large proportion of clients by reducing their intravenous drug use, HIV rates, and criminal activity, and by enhancing their social productivity. The most effective maintenance programs provide methadone as well as other medical, behavioral, and social services.

There are also medications used for alcohol treatment and include Naltrexone, which blocks the craving for alcohol, Acamprosate (Campral®), which helps the brains of people who have drunk large amounts of alcohol to work normally again, and Disulfiram (Antabuse®), which causes nausea and vomiting if consumed with alcohol.

What is relapse?

Relapse is the recurrence of psychoactive drug-dependent behavior in an individual who has previously achieved and maintained abstinence for a significant period of time beyond withdrawal. Relapse is not an isolated event, but a process whereby an individual becomes unable to cope with life in sobriety and thus can no longer avoid using alcohol or other drugs.

The process is often marked by identifiable and predictable warning signs that begin well before the return to use, such as a return of denial, defensiveness, irritability or restlessness, anxiety or depression. These emotions often lend themselves to such behaviors as seeking out situations which involve people who use alcohol or other drugs. In order to prevent relapse, the client may have to continue addressing the relapse issues for years after leaving treatment.

According to NIDA, relapse rates for addiction resemble those of other chronic diseases such as diabetes, hypertension, and asthma.

What steps can be taken to prevent or diminish the harm of relapse?

The same support systems that are necessary to propel an individual into treatment, such as friends and family members, are also necessary when facing actual or potential relapse. Family, friends and workplaces need to understand that relapse is a part of the recovery process, and that a relapse does not necessarily mean that a specific type of treatment has not been, or will not be, successful. They should continue to support the individual as if the relapse had not occurred, but realize that additional support, including a return to treatment, may also be necessary.

Drug testing is also a viable monitoring system. If individuals know that their drug-using behaviors will be monitored by an objective measure of drug use, and that any such drug use would have serious consequences (e.g., incarceration, termination from treatment or the workplace), they might be able to withstand the pressures of potential relapse.

Does the use of medications like methadone simply replace one drug addiction for another?

No. Methadone is not a heroin substitute. It is a safe and effective medication for opiate addiction. Maintenance treatment with methadone reduces the desire for heroin and the euphoric effects of heroin are significantly blocked. According to research, those undergoing maintenance treatment do not suffer the medical abnormalities and behavioral destabilization that rapid fluctuations in drug levels cause in heroin addicts. It should be noted, however, that according to the Federal Motor Carrier Safety Administration, commercial motor vehicle (CMV) drivers taking methadone cannot be qualified for a commercial driver's license.

What are the best treatment programs?

The best treatment programs are comprehensive and multidimensional. That is, the most effective programs are closely linked with a wide variety of treatment alternatives and support services. Because recovery is often a long and complex process, treatment providers must be able to adjust treatment to ensure that it is appropriate to the individual's changing needs. In addition to behavioral and/or medical alternatives, the client may need parenting instruction, vocational rehabilitation, and social and legal services.

Is drug treatment effective?

Research conducted within a variety of disciplines (e.g., criminology, health, psychology, and psychiatry) suggests that treatment is effective when clients are appropriately matched to services. It is critical, therefore, that the needs of the drug user be evaluated prior to treatment admission. Treatment success can be measured through a variety of measures, including, for example, drug abstinence, general well being, and sustained employment.

Overall, treatment of addiction is as successful as treatment of other chronic diseases such as diabetes, hypertension, and asthma. According to NIDA's publication, Principles of Drug Addiction Treatment: A Research Based Guide, drug treatment reduces drug use by 40-60% and significantly decreases criminal activity during and after treatment. Research by NIDA shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV-related illnesses. Injection drug users who do not enter treatment are up to six times more likely to become infected with HIV than injection drug users who enter and remain in treatment. Treatment can improve prospects for employment, with gains of up to 40% after a single treatment stay. Although these effectiveness rates hold in general, individual treatment outcomes depend on the extent and nature of the client's issues, the appropriateness of the treatment services utilized to address those issues, and the degree to which the client is actively engaged in the treatment process.

How long does drug addiction treatment usually last?

Individuals progress through drug addiction treatment at various speeds. Nevertheless, research by the Center for Substance Abuse Treatment (CSAT) has shown that length of stay is positively related to treatment outcomes and that increasing lengths of stay improve treatment outcomes. For residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer are often indicated. For methadone maintenance, 12 months of treatment is the minimum, and some opiate-addicted individuals will continue to benefit from methadone maintenance treatment over a period of years.

The length of drug addiction treatment is variable and is often contingent upon what type of treatment an individual needs, the type of healthcare benefit that person has and what the benefit provider will approve.

What options are there for finding appropriate treatment?

Finding treatment can be challenging for a variety of reasons including a lack of adequate treatment capacity or the inability to understand how to get approval for services. Some insurance plans, especially Behavioral Health Maintenance Organizations (BHMOs) have "gatekeepers" such as a primary care physician through whom an individual must go in order to access services and approve length of stay recommendations. Other plans provide a large list of providers yet may not specify the most appropriate program.

For those employees fortunate enough to have it, Employee Assistance Programs (EAPs), an employer-provided benefit for employees, provide confidential assessment services for substance abuse, among other services. They can help to determine the best treatment venue and can often be an advocate for employees seeking treatment. Most EAP professionals are familiar with various health insurance plans and the treatment providers available through those plans and are also familiar with how to work with the insurance system to access appropriate treatment. In addition, EAPs often monitor treatment recommendations for an employee to assure compliance and provide assistance with the employee returning to work following treatment.

Substance Abuse and Mental Health Services Administration's (SAMHSA) Substance Abuse Treatment Facility Locator is an on-line resource for locating drug and alcohol abuse treatment programs. It lists private and public facilities that are licensed, certified, or otherwise approved for inclusion by their State substance abuse agency and treatment facilities administered by the Department of Veterans Affairs, the Indian Health Service and the Department of Defense.

Does treatment have to be voluntary?

No. Treatment does not have to be voluntary to be effective. Strong motivations, such as sanctions or enticements in the family or workplace, can help facilitate entry and sustain treatment. Nevertheless, it is also true that for any treatment to be successful, the addict must become an active and compliant participant in the regimen.

What are the costs of treatment?

The costs of substance abuse treatment services can vary greatly depending upon the type of treatment, the length of treatment and geographic location, among other factors. The Substance Abuse and Mental Health Services Administration (SAMHSA) identified the costs of client drug abuse treatment in their 2004 Alcohol and Drug Services Study (ADSS) Cost Study. The average cost per admission was highest at $7,415 for outpatient methadone treatment and lowest at $1,433 for outpatient non-methadone treatment. Non-residential care had the highest average cost per enrolled client day of $76.13 and the average cost per outpatient visit for outpatient methadone treatment was $17.78, compared with $26.72 per visit for outpatient non-methadone treatment.

How can the costs of treatment be covered?

Many employers offer some form of health insurance to employees and their dependents. To determine what is covered through that benefit, the insurance plan or the company's benefits administrator should be contacted. Many insurers offer coverage for mental health (MH) services and/or substance abuse (SA) treatments; some only cover substance abuse if it co-occurs with mental illness. As already noted, some plans require a referral from a primary care physician before services can be received.

Insurance coverage for mental health (MH) and substance abuse (SA) benefits differs among plans, employers, and States. State laws may require insurers to provide a standard, minimal offering of MH and/or SA benefits although insurers are free to provide additional coverage. In general, mental health benefits are not as extensive as medical/surgical benefits and will require higher deductibles and co-payments in addition to any regular, fixed payments.

The following are common types of managed care health insurance plans:

  • HMO, Health Maintenance Organization - A plan that provides a selected set of health care services from doctors or health care providers within its network. These plans highlight preventive services.
  • FFS, Fee-for-Service - A health plan in which consumers may use any health care provider they choose. Providers are paid a fee for each health care service performed; the plan will either pay the doctors directly or will reimburse you for the cost of the service after you have filed an insurance claim. Fee-for-service plans are a type of indemnity insurance.
  • PPOs, Preferred Provider Organizations, are sometimes referred to as fee-for-service plans. PPOs differ from FFS plans in that they use a network of providers and usually charge lower fees.
  • POS, Point-of-Service plan - A plan that operates under a FFS plan and/or a HMO.

Medicare or Medicaid services may be available if an individual does not have access to an EAP or employer-sponsored health insurance. To determine eligibility for these and other government programs, and to determine what kinds of coverage are provided, contact the Centers for Medicare and Medicaid Services (CMS), CMS , at 1-877-267-2323 (TDD: 1-866-226-1819) and local State's department of insurance. On the web, contact information for individual State's department of insurance on NAIC . State mental health program contact information from the National Association of State Mental Health Program Directors is available at NASMHPD.

State mental health agencies can help in explaining how mental health services in individual States are funded. In publicly funded mental health centers, such as those run by State, city or county governments, the cost of many services is calculated according to what an individual can afford to pay. If a person has a lack of funds, services are still provided. This is called a sliding-scale, or sliding-fee, basis of payment. In addition, States which often work with Federal programs, such as Medicaid, provide financial assistance to eligible individuals or families. Information about medical and health care assistance is available at county/city social services departments, health and human services department, or Social Security office.

What are the cost-benefits of treatment?

According to research published in The Journal of Mental Health Policy and Economics,3 once a person enters into substance abuse treatment his or her total health care utilization and costs begin to drop. In fact, NIDA's statistics state that total savings can exceed costs by a ratio of 12 to 1. Prior to treatment, however, the utilization and costs are about twice as much compared to those who do not abuse substances. Substance abuse treatment has the ability to offset its own cost by reducing future health expenses. Further, according to NIDA, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. Major savings to the individual and to society also stem from fewer interpersonal conflicts; greater workplace productivity; and fewer drug-related accidents, including overdoses and deaths.


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Endnotes:
1 Comprehensive Assesment and Treatment Outcome Research. St. Paul. MN: CATOR Connection 1990.
2 The National Treatment Improvement Evaluation Study (NTIES): Highlights. DHHS Publication No. (SMA) 97-3156. Rockville,MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Scientific Analysis and Synthesis, Office of Evaluation, 1997, Table 4.
3 Harold D. Holder, Ph.D, "Cost Benefits of Substance Abuse Treatment: An Overview of Results from Alcohol and Drug Abuse," The Journal of Mental Health Policy and Economics 1998: 23-29.