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9.9: Treating Addiction

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    Learning Objectives
    • Describe the process and effectiveness of pharmacological approaches to substance-use treatment
    • Explain cognitive and behavioral approaches to treating substance-related disorders

    Drug addiction can be treated, but it’s not simple. Most patients need long-term or repeated care to stop using completely and recover their lives. Addiction treatment must help the person do the following:

    • stop using drugs
    • stay drug-free
    • be productive in the family, at work, and in society

    Depending on the severity of substance use disorder, and the given substance, early treatment of acute withdrawal may include medical detoxification. Of note, acute withdrawal from heavy alcohol use should be done under medical supervision to prevent a potentially deadly withdrawal syndrome known as delirium tremens.

    Therapists often classify people with chemical dependencies as either interested or not interested in changing. About 11% of Americans with substance use disorder seek treatment, and 40–60% of those people relapse within a year. Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that affect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.

    Principles of Effective Treatment

    Based on scientific research since the mid-1970s, the following key principles should form the basis of any effective treatment program:

    • Addiction is a complex but treatable disease that affects brain function and behavior.
    • No single treatment is right for everyone.
    • People need to have quick access to treatment.
    • Effective treatment addresses all of the patient’s needs, not just his or her drug use.
    • Staying in treatment long enough is critical.
    • Counseling and other behavioral therapies are the most commonly used forms of treatment.
    • Medications are often an important part of treatment, especially when combined with behavioral therapies.
    • Treatment plans must be reviewed often and modified to fit the patient’s changing needs.
    • Treatment should address other possible mental disorders.
    • Medically assisted detoxification is only the first stage of treatment.
    • Treatment doesn’t need to be voluntary to be effective.
    • Drug use during treatment must be monitored continuously.
    • Treatment programs should test patients for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as teach them about steps they can take to reduce their risk of these illnesses.

    What Are Treatments for Drug Addiction?

    There are many options that have been successful in treating drug addiction, including:

    • behavioral counseling
    • medication
    • medical devices and applications used to treat withdrawal symptoms or deliver skills training
    • evaluation and treatment for co-occurring mental health issues such as depression and anxiety
    • long-term follow-up to prevent relapse

    A range of care with a tailored treatment program and follow-up options can be crucial to success. Treatment should include both medical and mental health services as needed. Follow-up care may include community- or family-based recovery support systems. Various types of programs offer help in drug rehabilitation, including residential treatment (in-patient/out-patient), local support groups, extended care centers, recovery or sober houses, addiction counseling, mental health, and medical care. Some rehab centers offer age- and gender-specific programs.

    Drug or Addiction Counseling

    Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin, or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and cease substance abuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.

    Psychological dependency is addressed in many drug rehabilitation programs by attempting to teach the person new methods of interacting in a drug-free environment. In particular, patients are generally encouraged, or possibly even required, to not associate with peers who still use the addictive substance. Twelve-step programs encourage addicts not only to stop using alcohol or other drugs, but to examine and change habits related to their addictions. For legal drugs such as alcohol, complete abstention—rather than attempts at moderation, which may lead to relapse—is also emphasized (“One is too many, and a thousand is never enough.”) Whether moderation is achievable by those with a history of abuse remains a controversial point.

    Medications and devices can be used to manage withdrawal symptoms, prevent relapse, and treat co-occurring conditions.

    Withdrawal. Medications and devices can help suppress withdrawal symptoms during detoxification. Detoxification is not in itself “treatment,” but only the first step in the process. Patients who do not receive any further treatment after detoxification usually resume their drug use. One study of treatment facilities found that medications were used in almost 80% of detoxifications (SAMHSA, 2014). In November 2017, the Food and Drug Administration (FDA) granted a new indication to an electronic stimulation device, NSS-2 Bridge, for use in helping reduce opioid withdrawal symptoms. This device is placed behind the ear and sends electrical pulses to stimulate certain brain nerves. Also, in May 2018, the FDA approved lofexidine, a non-opioid medicine designed to reduce opioid withdrawal symptoms.

    Relapse prevention. Patients can use medications to help re-establish normal brain function and decrease cravings. Medications are available for the treatment of opioid (heroin, prescription pain relievers), tobacco (nicotine), and alcohol addiction. Scientists are developing other medications to treat stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. People who use more than one drug, which is very common, need treatment for all the substances they use.

    • Opioids: Methadone (Dolophine® and Methadose®), buprenorphine (Suboxone®, Subutex®, Probuphine® , and Sublocade™), and naltrexone (Vivitrol®) are used to treat opioid addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone blocks the effects of opioids at their receptor sites in the brain and should be used only in patients who have already been detoxified. All medications help patients reduce drug seeking and related criminal behavior and help them become more open to behavioral treatments. A NIDA study found that once treatment is initiated, both a buprenorphine/naloxone combination and an extended release naltrexone formulation are similarly effective in treating opioid addiction. Because full detoxification is necessary for treatment with naloxone, initiating treatment among active users was difficult, but once detoxification was complete, both medications had similar effectiveness.
    A cigarette butt with text underneath that reads, "Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times."
    Figure \(\PageIndex{1}\): Some people are able to quit cold turkey and never pick up their addiction again, but for most people, drug rehabilitation and treatment is a process with several ups and downs utilizing a variety of treatment methods, including medications and therapy.
    • Tobacco: Nicotine replacement therapies have several forms, including the patch, spray, gum, and lozenges. These products are available over the counter. The FDA has approved two prescription medications for nicotine addiction: bupropion (Zyban®) and varenicline (Chantix®). They work differently in the brain, but both help prevent relapse in people trying to quit. The medications are more effective when combined with behavioral treatments, such as group and individual therapy as well as telephone quit lines. A few antidepressants have been proven to be helpful in the context of smoking cessation/nicotine addiction. These medications include bupropion and nortriptyline. Bupropion inhibits the re-uptake of nor-epinephrine and dopamine and has been FDA approved for smoking cessation, while nortriptyline is a tricyclic antidepressant that has been used to aid in smoking cessation but has not been FDA approved for this indication.
    • Alcohol: Three medications have been FDA approved for treating alcohol addiction and a fourth, topiramate, has shown promise in clinical trials (large-scale studies with people). The three approved medications are as follows:
      • Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some patients. Genetic differences may affect how well the drug works in certain patients.
      • Acamprosate (Campral®) may reduce symptoms of long-lasting withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (generally feeling unwell or unhappy). It may be more effective in patients with severe addiction.
      • Disulfiram (Antabuse®) interferes with the breakdown of alcohol. Acetaldehyde builds up in the body, leading to unpleasant reactions that include flushing (warmth and redness in the face), nausea, and irregular heartbeat if the patient drinks alcohol. Compliance (taking the drug as prescribed) can be a problem, but it may help patients who are highly motivated to quit drinking.
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    Is Addiction a disease?

    Addictive drugs change the brain, genetic studies show that alcoholism has a substantial heritability, and addiction is a persistent, destructive pattern of drug use (e.g., Cloninger, 1987; American Psychiatric Association, 1994; Robinson et al., 2001). In scientific journals and popular media outlets, these observations are cited as proof that “addiction is a chronic, relapsing brain disease, involving compulsive drug use” (e.g., Miller and Chappel, 1991; Leshner, 1999; Lubman et al., 2004; Quenqua, 2011). Yet, research shows that addiction has the highest remission rate of any psychiatric disorder, that most addicts quit drugs without professional help, and that the correlates of quitting are those that attend most decisions, such as financial and familial concerns (e.g., Biernacki, 1986; Robins, 1993; Stinson et al., 2005; Klingemann et al., 2010).[1]

    However, addiction is disease-like in the sense that it persists even though its costs outweigh the benefits (e.g., most addicts eventually quit). Thus, in order to explain addiction, we need an account of voluntary behavior that predicts the persistence of activities that from a global bookkeeping perspective (e.g., long-term) are irrational. That is, addiction is not compulsive drug use, but it also is not rational drug use.[2]

    The disease theory is often interpreted as implying that problem drinkers are incapable of returning to normal, problem-free drinking, and therefore that treatment should focus on total abstinence. Some critics have used evidence of controlled drinking in formerly dependent drinkers to dispute the disease theory of alcoholism.

    The first major empirical challenge to this interpretation of the disease theory followed a 1962 study by Dr. D. L. Davies. Davies’ follow-up of 93 problem drinkers found that seven of them were able to return to controlled drinking (less than seven drinks per day for at least seven years). Davies concluded that “the accepted view that no alcohol addict can ever again drink normally should be modified, although all patients should be advised to aim at total abstinence”; After the Davies study, several other researchers reported cases of problem drinkers returning to controlled drinking.

    In 1976, a major study commonly referred to as the RAND report, published evidence of problem drinkers learning to consume alcohol in moderation. The publication of the study renewed controversy over how people suffering a disease that reputedly leads to uncontrollable drinking could manage to drink controllably. Subsequent studies also reported evidence of a return to controlled drinking. The most recent study, a long-term (60 year) follow-up of two groups of alcoholic men by George Vaillant at Harvard Medical School concluded that “return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence.” Vaillant also noted that “return-to-controlled drinking, as reported in short-term studies, is often a mirage.”

    How are behavioral therapies used to treat drug addiction?

    Behavioral therapies help patients to

    • modify their attitudes and behaviors related to drug use.
    • increase healthy life skills.
    • persist with other forms of treatment, such as medication.

    Patients can receive treatment in many different settings with various approaches.

    Outpatient behavioral treatment includes a wide variety of programs for patients who visit a behavioral health counselor on a regular schedule. Most of the programs involve individual or group drug counseling, or both. These programs typically offer forms of behavioral therapy such as

    • CBT, which helps patients recognize, avoid, and cope with the situations in which they are most likely to use drugs.
    • multidimensional family therapy—developed for adolescents with drug abuse problems as well as their families—which addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.
    • motivational interviewing, which makes the most of people’s readiness to change their behavior and enter treatment.
    • motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.

    Treatment is sometimes intensive at first, where patients attend multiple outpatient sessions each week. After completing intensive treatment, patients transition to regular outpatient treatment, which meets less often and for fewer hours per week to help sustain their recovery.

    Mutual Help Groups

    A group of people sitting in a circle.
    Figure \(\PageIndex{2}\): Support groups such as Alcoholics Anonymous are beneficial in recovering from an addiction.

    In a support group, members provide each other with various types of help, usually nonprofessional and nonmaterial, for a particular shared, usually burdensome, characteristic. Members with the same issues can come together for sharing coping strategies, to feel more empowered, and for a sense of community. The help may take the form of providing and evaluating relevant information, relating personal experiences, listening to and accepting others’ experiences, providing sympathetic understanding and establishing social networks. A support group may also work to inform the public or engage in advocacy.

    Membership in some support groups is formally controlled with admission requirements and membership fees. Other groups are open and allow anyone to attend an advertised meeting, for example, or to participate in an online forum.

    A self-help support group is fully organized and managed by its members, who are commonly volunteers and have personal experience in the subject of the group’s focus. These groups may also be referred to as fellowships, peer support groups, lay organizations, mutual help groups, or mutual aid self-help groups. Most common are 12-step groups such as Alcoholics Anonymous and self-help groups for mental health. Alcoholic Anonymous (AA), is a voluntary program for people with alcoholism/AUD, based on belief on a spiritual basis for recovery. Members attend meeting and experiences are shared and “Twelve steps towards Recovery” are discussed. Avoiding alcohol and benefits of avoiding alcohol are discussed. Abstinence is encouraged on a daily or weekly basis.

    Watch It

    This video highlights some effective treatment options for substance use disorders.

    You can view the transcript for “Substance Use Treatment” here (opens in new window).

    Try It

    1. Heyman GM (2013) Addiction and choice: theory and new data. Front. Psychiatry 4:31. doi: 10.3389/fpsyt.2013.00031 ↵
    2. Heyman GM (2013) Addiction and choice: theory and new data. Front. Psychiatry 4:31. doi: 10.3389/fpsyt.2013.00031 ↵
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