Drug addiction, clinically referred to as a substance use disorder (SUD), is a disease that impacts millions of people. Fortunately, addiction is a treatable disorder, and long-term recovery is possible.
Drug addiction is a complicated disease that is often characterized by intense, uncontrollable drug craving and compulsive drug seeking/use that persist during potentially devastating consequences. Addiction is a brain disease as it affects multiple brain circuits, including those involved in learning, memory, reward, motivation, and repressive management of behavior. Like treatment for other chronic diseases such as heart disease or asthma, addiction treatment is not a cure. It is a way of managing the condition.
Treatment enables people to counteract addiction’s disruptive effects on their brain and behavior and regain control of their lives. Most patients cannot simply stop using drugs for a brief time and be cured. Patients typically require long-term care to achieve sustained abstinence and recovery. Scientific research and clinical practice demonstrate the value of continuing care in treating addiction, with a variety of approaches. Treatment is not simple because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life. Effective treatment programs typically incorporate several components, each directed to a particular aspect of the illness and its consequences. Addiction treatment should help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society.
If a person is ready to take the first step in recovery, help is immediately available. There are treatment options that can help establish and achieve long-lasting recovery. Effective addiction treatment is unique to everyone, and that treatment plan includes comprehensive interventions that are tailored to a person’s health and overall recovery needs and may include:
- Detox. Medically managed detox helps rid the body of substances safely and as comfortably as possible. Healthcare professionals may utilize medication and other interventions to help prevent and/or alleviate withdrawal symptoms. Detox, alone, however, is not typically enough to sustain recovery. It is typically the first step in a more comprehensive treatment program.
- Inpatient treatment. Sometimes referred to as residential treatment, inpatient programs require the addict to live at the facility for the duration of treatment and participate in education, individual and group counseling, and behavioral therapies.
- Outpatient treatment programs. Outpatient treatment varies in intensity, depending on the program. An individual travels to a facility for a specified number of hours each day on specified days per week and then returns home or to a sober living environment at the end of each day. Beyond that, treatment looks very similar to the interventions and services provided in an inpatient setting.
Behavioral therapies are effectively used in the treatment of addiction. Common therapies used in SUD treatment include:
Cognitive-behavioral therapy (CBT). CBT promotes the learning of healthy cognitive and behavioral skills to replace maladaptive ways of thinking and behaving that contribute to drug and alcohol use.
Contingency management (CM). Contingency management uses rewards to reinforce recovery goals, such as maintaining abstinence or attending therapy.
Motivation therapy (MT). This therapy aims to end any uncertainty a person may have about ending addiction and motivates a person to enter and remain in treatment.
CBT for substance use disorders includes several distinct interventions, either group formats or individual sessions. One area of intervention focuses on motivation. At the outset, motivation for treatment and the likelihood of adherence must be considered. MT is an approach based on targeting indecision toward behavior changes relative to drug and alcohol use. There would then be subsequent application to motivation and adherence related to a wide variety of other disorders and behaviors, including increasing adherence to CBT for anxiety disorders.
Once treatment has begun, a primary challenge is dealing with the robust reinforcing effects of the drugs. CM approaches involve the administration of a non-drug reinforcer, such as vouchers for items, following demonstration of abstinence from substances. To allow for greater cost efficiency of CM approaches, researchers investigated the role of lottery-type strategies for distribution of reinforcers. For example, the punchbowl method rewards negative screens for drug use with the opportunity to draw a prize from a “punchbowl”. Most prizes have low monetary value (e.g. $1), but the inclusion of a few large prizes (e.g. $50) saves money yet offers a successful inducement for abstinence. CM procedures may use stable or escalating reinforcement schedules, in which the reinforcement value increases as duration of abstinence increases. Adaptive behaviors ranging from attendance to prenatal visits to medication adherence have also been successfully changed using these same reinforcement schedules. A limitation of CM can be the inability to support funding this method in clinical settings.
Relapse prevention is another well-researched CBT approach to treat drug abuse that emphasizes a functional analysis of cues for drug use and systematic training of alternative responses to these cues. This approach focuses on the identification and prevention of high-risk situations when a patient is more likely to engage in substance use. Techniques of this approach include challenging the patient’s expectation of perceived positive effects of use and providing psychoeducation to help the patient make a more informed choice in the threatening situation. This approach has a greater effect on improvement in overall psychosocial adjustment than it does in reducing substance abuse.
While substance abuse treatments often occur in an individual or group format, the disorder itself has strong ties to the patient’s social environment. Because of this, several promising treatments have been developed that utilize the support of the partner, family, and community to aid the patient in achieving abstinence. The Community Reinforcement Approach (CRA) focuses on altering possibilities within the environment to make sober behavior more rewarding than substance use.
Behavioral Couples Therapy (BCT) is another treatment that utilizes the support of a significant other in treatment of the addict. With this treatment, it is assumed that there is reciprocal relationship between relationship functioning and substance abuse, whereby substance use can have a detrimental effect on the relationship and this relationship distress can lead to increased substance use. Therefore, the focus of this treatment involves improving a partner’s coping with substance-related situations as well as improving overall relationship functioning. Interventions typically include psychoeducation training in withdrawal of relationship contact contingent on drug use, and the application of reinforcement (e.g., enhanced recognition of positive qualities and behaviors) contingent on drug free days. This includes the scheduling of mutually pleasurable non-drug activities to decrease opportunities for drug use and to reward abstinence.
Once high risk situations and events are identified (including people and places, as well as the internal cues such as changes in affect), cognitive behavior therapy can be directed to altering the likelihood that these events are encountered (providing alternative non-drug activities, or activities with non-drug using individuals) as well as rehearsing non-drug alternatives to these cues. Motivational and cognitive interventions can be provided to enhance motivation for these alternative activities as behavior, while also working to decrease cognitions that enhance the likelihood of drug use. Also, broader cognitive strategies can target cognitive distortions specific to substance abuse, including rationalizing use and giving up. In such circumstances, eliciting evidence from the patient regarding the accuracy of these thoughts can help to identify alternative appraisals that may be more adaptive and better reflect the patient’s experience. Similarly, providing psychoeducation on the nature of such thoughts and the role that they may play in recovery can help the patient to gain awareness about how such thinking patterns contribute to the maintenance of the disorder. As with other disorders, rehearsal of cognitive restructuring in the context of drug cues may enhance the availability of these skills outside the treatment setting.
In addition to the elements of motivational interviewing (i.e., assessment, dispassionate presentation of information, and explanation and discussion of uncertainty about drug abstinence), broader cognitive strategies can target the cognitive distortions specific to substance abuse, including rationalizing use (e.g., “I will just use this once,” “One drink won’t hurt me,” “It has been a bad day; I deserve to use”) and giving up (e.g., “Why even try,” “I will always be an addict”). In such circumstances, eliciting evidence from the patient regarding the accuracy of these thoughts can help to identify alternative appraisals that may be more adaptive and better reflect the patient’s experience. Similarly, providing psychoeducation on the nature of such thoughts and the role that they may play in recovery can help the patient to gain awareness about how such thinking patterns contribute to the maintenance of the disorder. As with other disorders, rehearsal of cognitive restructuring in the context of drug cues may enhance the availability of these skills outside the treatment setting.
As part of cognitive restructuring, expectations, or beliefs about the consequences of use, are another important target for intervention. It is common to find that patients maintain a belief that use of a particular substance will help some problematic aspect of their life or given situations. For example, a patient may believe that a family holiday would not be enjoyable without alcohol use. Similar to cognitive restructuring techniques, evaluating evidence for expectations and designing behavioral experiments can be used to target this issue. In this instance, the patient would be encouraged to refrain from drinking at the holiday party and assess the degree to which the event was enjoyable. In addition, the patient could evaluate evidence from past holidays to compare the consequences and benefits of alcohol use in this setting.
Skills building targets interpersonal, emotion regulation, and organizational/problem-solving deficits. Clinical trials examining the addition of coping and communication skills training have demonstrated positive outcomes and are common components of CBT for substance abuse. Interpersonal skill building exercises may target repairing relationship difficulties, increasing the ability to use social support, and effective communication. For patients with strong support from a family member or significant other, the use of this social support in treatment may benefit both goals for abstinence and relationship functioning. In addition, the ability to reject offers for substances can be a limitation and serve as a challenge to recovery. Rehearsal in session of socially acceptable responses to offers for alcohol or drugs provides the patient with a stronger skill set for applying these refusals outside of the session. Where relevant, this rehearsal can be supplemented by emotional instruction to increase the degree to which the rehearsal is like the patient’s high-risk situations for drug use.
Emotion regulation skills can include distress tolerance and coping skills. Using problem-solving exercises and the development of a repertoire for emotion regulation, the patient can begin to both determine and utilize non-drug use alternatives to distress. Strategies for coping with negative affect, such as using social support, engaging in pleasurable activities, and exercise can be introduced and rehearsed in the session. The development of pleasurable sober activities is of particular importance given the amount of time and energy that is often used for substance use activities (i.e., obtaining, using, and feeling the effects of substances). When reducing substance use, patients can be left with a sense of absence where time was dedicated to use, which can serve as an obstacle to abstinence so concurrently increasing pleasant and goal-directed activities while reducing use can be crucial for facilitating initial and maintained abstinence.
Finally, goal-setting deficits can be targeted within the session as part of treatment. Guiding patients in setting treatment goals can serve as a first practice of this skill building. Also assisting patients in setting smaller goals in the service of longer-term goals is an important exercise. The inability to delay long-term pleasure for short-term pleasure is a characteristic feature of substance use disorders, and the ability to set long-term goals may be compromised. Particularly for patients with more severe substance dependence, skills building may require shifting the patient’s relevant skills and goals from that of an illicit lifestyle to that of a more normative lifestyle so the skills that may have been adaptive while actively using—interpersonal skills needed to obtain drugs and to connect with other substance users, the ability to manipulate those around you, to do things without being caught—may translate poorly to reconnecting with family and sober friends, obtaining and maintaining a job, and building healthy life activities.
There are many clinical challenges that may arise in the treatment of substance use disorders that can serve as barriers to successful treatment. These include acute or chronic cognitive deficits, medical problems, social stressors, and lack of social resources. In addition, certain populations, such as pregnant women and incarcerated patients, may present particular challenges. In each of these circumstances, the use of functional analysis to arrive at strong case conceptualization and the flexible utilization of treatment components is important. For example, among individuals with low levels of literacy, the use of written homework forms may need to be replaced by alternative means of monitoring home practice (e.g., using simplified forms or having the patient call to leave a phone message regarding completion of an assignment).
One challenge can be the shift in the social and environmental contexts associated with use relative to non-use lifestyles. For example, among individuals who have long histories of substance misuse, there are often significant life consequences, such as unemployment, family difficulties, reduced social networks, etc. In such groups, their fit to society is within the context of others with similar misuse problems. The illicit drug use culture, characterized at times by other illicit behaviors (e.g., drug dealing, theft, prostitution) and the valuation of particular skills (e.g., the ability to make a drug deal at 2:00AM), varies dramatically from a more mainstream culture. So in treatment, the patient not only is being asked to transition to a culture in which he or she may have few skills and resources, but also to relinquish the parts of his or her life in which there is a sense of effectiveness and belonging. The sense of belonging to the substance use culture can increase disregard for change, particularly when measurable life changes occur at slow pace. In such cases, it is critical to establish alternatives for achieving a sense of belonging, including both social connection and effectiveness. Depending on the resources available to the patient, this may include joining some type of social group (e.g., a sports club), volunteer work, or other activity-based social opportunities.
Because addiction can affect so many aspects of a person’s life, treatment should address the needs of the whole person to be successful. Counselors may select from a menu of services that meet the specific medical, mental, social, occupational, family, and legal needs of their patients to help in their recovery. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society.
At Avance Care, our Behavioral Health therapists and Avance Psychiatry teams offer care for those with SUD and are seeking treatment. Contact us to learn more about our services and schedule an appointment.
References:
- https://nida.nih.gov/publications/drugs-brains-science-addiction/treatment-recovery
- https://ncbi.nlm.nih.gov/pmc/articles/PMC2897895
- https://americanaddictioncenters.org/addiction-recovery
