Chapter 3–Causes of Addiction and Modalities for Treatment

Personality Traits

The use of drugs is linked with emotional problems and personal inadequacies according to this school of thought. Substance abuse may provide the individual with an escape from the problems of life through euphoria and drug-induced indifference. Although such drug use may mask certain difficulties temporarily, the underlying problems are not solved, and addiction generates new, and often more serious, problems (Goode, 1972).

As a response to psychological suffering, substance abuse is sometimes viewed as an adaptive effort for survival. Associations have been found between drug use and psychological characteristics such as low self-esteem, low self-confidence, low self-satisfaction, need for social approval, high anxiety, low assertiveness, greater rebelliousness, and self-regulatory deficiencies. The causes of these characteristics have been attributed variously to factors such as peer rejection, parental neglect, high achievement expectations, school failure, social and physical stigma, and poor coping ability, among others. Deviant activity, such as substance abuse, may be chosen by some as a way of achieving group acceptance, status, and membership or escaping the realities of rejection (Brehm & Khantzian, 1992; Goode, 1972; Schinke, Botvin & Orlandi, 1991). Some research indicates that Antisocial Personality Disorder and Borderline Personality Disorder may place persons at increased risk of substance abuse (Mirin & Weiss, 1991).

Based on the concept of reinforcement, behavioral treatment approaches often try to help individuals find significantly greater rewards from legitimate activities. Involvement in a variety of activities, depending on individual interests and abilities, may help some persons achieve greater peer acceptance and self-esteem. Substituting other activities to achieve feelings of happiness and well-being also are recommended. For example, some persons claim to get a "high" from running or other physical activities. Virtually all of the prevailing psychosocial treatment approaches emphasize helping chemically dependent persons learn new ways to structure their time and social relationships through drug-free activities.

Relapse prevention, a critical component of treatment, is closely tied to drug cues. Approaches are recommended for helping individuals control or change their reactions to drug cues. Avoiding people, places, and activities formerly associated with substance abuse is one example. Relapse prevention is a critical element of any treatment approach. Chapter 9 will provide more information on relapse prevention.

Aversive conditioning is a technique that involves pairing a negative stimulus with drug cues. Some methods that have been tried include chemically or hypnotically induced nausea or electric shocks paired with the sight, taste, smell, or other reminders of specific substances. Another approach, sometimes called extinction or cue exposure, consists of presenting the drug cue repeatedly. However, in controlled settings, where this cue cannot be followed by alcohol or drug use, reaction to the stimulus is gradually reduced. Substance abusers also may receive skills training and cognitive behavioral counseling to provide them with tools to avoid relapsing to alcohol or other drug use (Childress et. al., 1992; Siegel, 1988).

A variety of therapeutic interventions may be implemented in addressing the personal and emotional problems thought to underlie substance abuse. Traditional mental health approaches may include building self-esteem, lowering anxiety, and resolving other distressful problems through individual, group, and family counseling.

Behavioral or psychosocial treatment approaches often are linked to a clinical understanding of addiction. These methods include self-help and individual, group, and family counseling. All rely heavily on changing the individual's self-concept and dealing with distressing situations and relationships thought to underlie substance abuse.

Social Causes of Substance Abuse

These perspectives focus on situations, social relations, or social structures related to substance abuse. Virtually any factor outside the individual, such as peers, family, or the media, could be associated with social causes of addiction.

Social Learning

In group settings, individuals are exposed to persons who model certain behaviors, and they receive rewards or punishments for their own behaviors from group members. When one associates with groups that define drug use as desirable and whose members model drug-related behavior, drug use by the individual is learned and rewarded (Goode, 1972).

Subculture Perspectives

This viewpoint indicates that drug use is expected and encouraged in certain social circles, while it is discouraged, and even punished, in others. There is not a single drug subculture; rather, there are several of them. For example, there might be a drug subculture of white, high school youth, or young adult black males, and some drug subcultures are formed according to the drug of choice (e.g., groups for alcohol, marijuana, cocaine, or heroin users). Members of a subculture teach new members how to use a particular drug, supply the drug initially, and provide role models (Goode, 1972).

Socialization

According to this perspective, potential drug users are attracted to other drug-involved individuals and drug subculture groups because their own values and activities are compatible with those of persons who use drugs. The four main agents of socialization for adolescents are parents, peers, school, and the media. The greater the youth's affinity for drug use, the more likely he or she is to choose to participate with others having similar values and norms. Alienation from parents and friendship with drug-using peers are especially strong factors in the socialization of youth into drug use (Goode, 1972).

Social Control

This approach claims that absence of the social control requiring conformity leads to drug abuse. Those more attached to conventional society are less likely to engage in behavior that violates societal values and norms. Socially detached persons will not feel the constraint of these norms and values (Goode, 1972).

Social, Economic, and Political Factors

Elements of unemployment, poverty, racism, sexism, family dissolution, and feelings of powerlessness and alienation are associated with the problem of substance abuse. Although not universal by any means, some persons consistently subjected to these conditions are drawn into drug activity to escape their painful life circumstances (Haddock & Beto, 1988; Lowinger, 1992).

One approach to treating substance abuse from the social perspective involves changing the substance abuser's environment and peer associations. The behavioral treatment approaches emphasize positive peer associations and pro-social lifestyles and activities. For example, therapeutic communities are based on group support and confrontation to help members learn new attitudes and behaviors toward drugs and other persons (NIDA, 1991). Self-help strategies similarly encourage drug-free activities and association with others in recovery.

Working to strengthen social values and norms that preclude drug dependency also is important. Our society generally is committed to eliminating pain, suffering, and discomfort (Serban, 1984). Millions of dollars are spent on advertising products such as patent medicines, alcohol, and tobacco as "quick cures" for physical and emotional distress. Promoting and glamorizing the use of such substances contributes to an attitude that drinking and other drug use is acceptable and even desirable. Instant gratification is an underlying theme throughout most of American society.

Treatment strategies must consider more than just the individual affected by substance abuse. Considerations of economic, political, and social changes are also important concerns of treatment professionals and decision makers.

The Role of Detoxification

Detoxification is not a treatment modality, but is the necessary first step in the treatment process. Detoxification provides medical and supportive services needed to alleviate the short-term symptoms of physical withdrawal from chemical dependence, including physical discomfort and cravings, as well as mood changes (Institute of Medicine, 1990; ONDCP, 1990). Once symptoms of craving and withdrawal are controlled, treatment can begin.

The purpose of detoxification is to help the patient stabilize physically and psychologically until the body becomes free of drugs or the effects of alcohol. Within this broad goal there are several additional objectives that can be targeted. Promoting the health of the individual can be accomplished through measures to reduce and control seizures that occur with some drugs. It also includes screening for and treating infectious diseases and other medical problems. Drug education and relapse prevention programming can begin during detoxification. Some attention may even be given to family, vocational, religious, and legal problems in some settings. It is also important that detoxification be used as an opportunity to recruit and prepare persons for appropriate longer-term treatment programs (Alling, 1992; Institute of Medicine, 1990; ONDCP, 1990).

There are three major categories of abused substances that often require detoxification: (1) alcohol and other central nervous system (CNS) depressants; (2) opiate drugs; and (3) cocaine. Some of the major considerations for each are described.

Alcohol Detoxification

Following withdrawal from alcohol, a dependent person may experience several symptoms, including:

• eating and sleep disturbances;
• tremors (involuntary trembling motion of the body);
• sweats;
• clouding of the sensorium;
• hallucinations;
• agitation;
• elevated temperature;
• change in pulse rate; and
• convulsions.

Some of these symptoms can be life-threatening (Alterman, O'Brien & McLellan, 1991). In addition, the potential for suicide must be considered. Because of the possibility of these extreme consequences, there should be clearly defined procedures to follow when an individual is experiencing alcohol detoxification. These should be implemented in a variety of settings, including jails, shelters, and other congregate living situations.

Alcohol detoxification is usually provided in a hospital setting for five days or less. Medical supervision is needed to provide medications, vitamin therapy, and, in some cases, measures to correct water and electrolyte imbalances. Alcohol detoxification also may be provided in nonhospital settings, but the rates of successful completion have been much lower. Patients who need medical or psychiatric care, have no housing, have coexisting drug dependence, are unemployed, or come to the initial visit intoxicated are less likely to succeed in outpatient treatment and are more likely to need hospitalization (Alterman, O'Brien & McLellan, 1991).

Medications that can be useful in the treatment of alcohol withdrawal include benzodiazepines and other CNS depressants such as barbiturates. Clonidine and beta blocking drugs may help decrease symptoms of tremor, fast heart rate, and hypertension (Schuckit, 1989).

Detoxification From Other CNS Depressants

This category includes sedative drugs (such as barbiturates), hypnotic drugs (such as methaqualone), and anxiolytics, used for the treatment of anxiety. These drugs have legitimate medical uses, but they are also subject to misuse. Signs of abuse and dependency include:

• gradually increasing use;
• periods of intoxication;
• functional impairment; and
• unsuccessful attempts to decrease or discontinue use.

Sudden discontinuation of these drugs may result in life-threatening withdrawal (Alling, 1992). Again, procedures should define steps to be taken to ensure the safety of individuals withdrawing from CNS depressants. Signs of withdrawal include (Alling, 1992):

• tremor (involuntary trembling);
• hyperreflexia (increased/ heightened sense of reflex);
• agitation;
• hypertension (high blood pressure);
• tachycardia (excessively rapid heart beat);
• insomnia;
• vomiting, nausea;
• diaphoresis (excessive perspiration);
• cognitive impairment (memory loss, decreased ability to concentrate);
• seizures;
• weakness;
• anorexia;
• irritability;
• anxiety, restlessness;
• headache;
• muscle aches;
• depression;
• tinnitus (buzzing, whistling, or ringing sound in the ears);
• depersonalization (a state of impersonality, not of one's usual character);
• paranoid delusions; and
• hypersensitivity to touch, light, and sound.

Detoxification from these drugs is achieved by gradually reducing the amount of the substance used or by substituting a similar acting drug and then gradually with-drawing it by decreasing the dosage. Phenobarbital is an often-used drug substitute for this purpose (Alling, 1992).

Detoxification From Opiate Drugs

Detoxification from opiate drugs is needed as an initial treatment for opiate dependence (usually heroin) when addicts are entering a drug-free rehabilitation program. Detoxification also may be implemented when a person who has been stabilized on methadone wishes to discontinue its use. According to recent regulations by the FDA, methadone can be used for detoxification for up to 180 days (Alterman, O'Brien & McLellan, 1991).

Some of the more common symptoms of opiate withdrawal include the following (Alling, 1992):

• increased blood pressure, pulse rate, and temperature;
• piloerection ("gooseflesh");
• increased pupil size;
• rhinorrhea (nasal drainage/ mucus, can be excessive);
• lacrimation (excessive secretion of tears, heavy tearing);
• tremor;
• insomnia;
• vomiting, nausea;
• muscle aches;
• abdominal cramps;
• irritability;
• anorexia;
• weakness/tiredness;
• restlessness;
• headache;
• dizziness/lightheadedness;
• sneezing;
• hot or cold flashes; and
• drug craving.

The most common approach to detoxification from opiate drugs is the substitution of a longer-acting opioid, such as methadone, which blocks symptoms of withdrawal and drug cravings. The amount of methadone can then be gradually reduced. Combined with counseling services, methadone can help addicts quit using illicit drugs. It has reduced criminal behaviors associated with obtaining and taking illicit drugs. Vocational and educational services, coupled with cessation of illegal drug use, can help individuals lead more stable and productive lives. Clonidine is another drug that is used sometimes because it can block many of the signs and symptoms of opiate withdrawal. Acupuncture and electrostimulation of the central nervous system have also been used to alleviate withdrawal symptoms of opiate drugs. Reducing injection drug use and needle sharing among heroin addicts also diminishes the risk of contracting or spreading HIV and other substance abuse-related infectious diseases (Alling, 1992; Alterman, O'Brien & McLellan, 1991; Centers for Disease Control, 1989; U.S. General Accounting Office, 1990).

Detoxification From Cocaine

Cocaine dependence results in a period of physical and mental instability upon discontinuation of use. The usual pattern of cocaine use involves "binges" or "runs" lasting from 12 to 36 hours during which the person consumes all the cocaine available. Following this are periods usually lasting several days during which no cocaine is used and detoxification occurs (Alterman, O'Brien & McLellan, 1991; Institute of Medicine, 1990). The effects of withdrawal include:

• irritability;
• weakness;
• reduced energy;
• hypersomnia (an excessive feeling of sleepiness, fatigue);
• depression;
• loss of concentration;
• diminished capacity to experience pleasure;
• increased appetite; and
• paranoid ideations.

In addition, the cocaine-dependent person will experience cravings for the drug, leading to another episode of binging on the drug (Alterman, O'Brien & McLellan, 1991; Institute of Medicine, 1990). Detoxification efforts have focused on ways of managing withdrawal symptoms and cravings long enough to disrupt the cycle of binging and craving. Drugs that have been used to counteract cocaine withdrawal problems include:

• desipramine hydrochloride;
• amantadine;
• bromocriptine;
• flupenthixol decanoate; and
• buprenorphine.

These are usually administered on an outpatient basis and accompanied by counseling. However, for persons with concomitant psychiatric or medical problems (e.g., pregnancy, myocardial damage) inpatient care is recommended. Patient dropout rates for these treatments (especially outpatient programs) tend to be high, because it usually takes one to two weeks for the therapeutic effects of medications to begin (Alterman, O'Brien & McLellan, 1991; Institute of Medicine, 1990). In the interim, the cycle of craving and cocaine use may continue.

Addiction is considered a medical illness with related psychological and social dimensions. As reviewed in Chapter 1, substance abuse problems progress from experimental to addictive use for some people. This process occurs more quickly for some people than it does for others. Detoxification is necessary to prepare patients for the treatment process. It is particularly important for those who have become dependent on alcohol and other CNS depressants, opiate drugs, and cocaine. Until the body is free of the effects of the drugs and the distorted thoughts and feelings they produce, it is difficult for recovery to begin.

Studies have shown that rapid relapse is likely to follow detoxification unless patients become engaged in additional treatment and transition services. Persons completing a detoxification program without continuing treatment are no more likely to succeed in reducing future drug use than persons achieving unassisted withdrawal.

The use of methadone has been well researched, and its effectiveness as part of the detoxification process for opiate drugs has been supported. However, many other drug treatments for alleviating withdrawal symptoms either have not been well researched or have resulted in contradictory findings. Thus, this is an area requiring additional medical research. As with any medical problem, when medications, such as methadone, Antabuse, and others, are used, supervision by a physician is required.

There also are varied findings regarding the preference of inpatient or outpatient care. Inpatient care is clearly necessary when the individual has associated psychiatric or medical problems. Because of the potential for life-threatening withdrawal symptoms, alcohol detoxification often takes place in a hospital or other medical facility. Patient retention in detoxification programs also has been significantly greater with inpatient programs compared to outpatient care. However, some research findings are emerging indicating that outpatient alcohol detoxification may be as beneficial in many cases and is much more cost-effective (Alterman, O'Brien & McLellan, 1991; Institute of Medicine, 1990).

The Institute of Medicine (1990) recommends that hospital-based drug detoxification be used only if medical complications occur or when appropriate residential or outpatient facilities are not available. The conditions for which hospital-based drug detoxification is recommended include:

• serious concurrent medical illness such as tuberculosis, pneumonia, or acute hepatitis;
• history of medical complications such as seizures in previous detoxification episodes;
• evidence of suicidal ideation;
• dependence on sedative-hypnotic drugs; and
• history of failure to complete earlier ambulatory or residential detoxification.

Treatment for Alcohol and Other Drug Problems

Some persons who use drugs do not need drug treatment. Many people can use alcohol and some illicit drugs without encountering adverse consequences. Some grow weary of a lifestyle in which the pursuit of drugs and managing the varied consequences of substance use predominates. Most people who have not progressed to the point of dependency or addiction are able to decide to stop using drugs and maintain this resolve. However, a social climate that is intolerant toward substance abuse and the risk of social, legal, or employer sanctions may be needed for them to make and maintain their decision to stop or limit their drug use (ONDCP, 1990).

For those who are dependent or addicted, treatment for substance abuse is crucial in controlling their substance abuse and improving their health and social functioning. Without treatment, substance abuse may ultimately be fatal because of the risk of overdose, related suicides and homicides, and infectious diseases and other assaults to one's health. Yet few voluntarily seek treatment. Cessation of drug use is very difficult and treatment programs can be demanding and intense (ONDCP, 1990).

However, for those who enter and remain in treatment, the news is often positive. Research indicates that treatment is effective and many drug- and alcohol-involved persons respond favorably to a diversity of treatment approaches (NIDA, 1991).

Major Treatment Modalities

There is no "magic bullet" for effectively treating persons with substance abuse problems. Different people respond to various approaches in diverse ways. The effects of various substances of abuse produce different symptoms and needs among users. As indicated earlier, there are diverse ways in which the causes and progression of drug and alcohol addiction may be understood. This makes it critically important that individuals be matched appropriately with the treatment program or modality that is most likely to attack the problems resulting in their particular needs; the most successful treatment is individualized. Many factors must be considered, including personality, background, mental condition, and drug use experience (ONDCP, 1990). More information on treatment matching will be provided in Chapter 5.

There are several ways to categorize treatment programs and modalities. In this text they will be grouped into two broad categories:

1. Those that are biologically based, including:
   • pharmacotherapeutic treatment
   • acupuncture
2. Those that are behaviorally or psychosocially based, including:
   • residential or inpatient treatment programs, such as:
     • inpatient hospitalization
     • therapeutic communities
   • outpatient nonmethadone treatment

Various treatment components and approaches are used in these treatment programs and modalities, including:

• self-help programs;
• individual counseling;
• group counseling/treatment;
• family therapy; and
• behavior modification.

After a summary of detoxification, the first step in treatment for drug-dependent persons, the remainder of this chapter will provide a brief description of each of the major treatment approaches commonly found in the United States. General information about each treatment method will be provided, realizing that approaches can vary markedly because of differences in settings, professional staff, and client characteristics. Available information about the effectiveness of each of these modalities also will be provided.

Pharmacotherapeutic Modalities

Substance abuse, by definition, is a chronic disease in which the use of psychoactive substances may result in both physical and psychological addiction. Thus, one treatment approach that has shown favorable outcomes is pharmacotherapy–the use of approved medications with medical supervision. The goals of pharmacotherapy include (Lowinson, Marion, Joseph & Dole, 1992):

• reduction in the use of illicit drugs or alcohol;
• reduction in criminal behavior; and
• improvement of social behavior and psychological well being.

A further goal is the urgent imperative to control and prevent the spread of substance abuse-related infectious diseases, such as HIV/AIDS and tuberculosis. For those already infected, treatment for alcohol and other drug addiction may stabilize their physical condition, boost the immune system, and delay or prevent the onset of serious illness.

More research has been conducted on drug therapies for opiate drugs and alcohol than on other categories of abused substances. There are four categories of pharmacological treatment for substance abuse. Each will be defined, followed by some examples of the more common pharmacotherapeutic agents. A more extensive discussion of pharmacotherapy can be found in Chapter 8.

Agonists

These drugs can be substituted for the drug of abuse to provide a more controllable form of addiction. The properties and actions of these drugs are similar to those of particular abused drugs. Using them alleviates many of the withdrawal symptoms often experienced by persons addicted to various psychoactive substances. Examples of drugs in this category include methadone, clonidine, and LAAM.

Methadone, a synthetic narcotic analgesic compound, is the most commonly used form of pharmacotherapy for opiate drugs. It is medically safe and has few side effects. It produces a stable drug level and is not behaviorally or subjectively intoxicating. It blocks the cravings for opiate drugs and does not produce euphoria, as heroin and other drugs do. The characteristics of methadone patients have changed considerably over the past decade because of increased rates of HIV infection among intravenous drug abusers, concomitant use of cocaine and crack, and homelessness. These changes have resulted in methadone programs' needs for enlarged and more sophisticated physical facilities, better trained staff, and more funding (Lowinson, Marion, Joseph & Dole, 1992).

Among the various pharmacotherapies, methadone maintenance has been studied most thoroughly. Methadone maintenance is generally successful in meeting treatment goals. When appropriate doses of methadone are administered, heroin use decreases markedly. However, in some cases other drugs, such as cocaine and alcohol, continue to be used. A substantial reduction in criminal behavior has been documented by several studies, and this reduction increases with length of time in methadone treatment. Socially productive behavior, such as employment, education, or homemaking, has also been shown to improve with the length of time in treatment (Lowinson, Marion, Joseph & Dole, 1992).

Clonidine can partially suppress many withdrawal symptoms of opiates, alcohol, and tobacco. It is most effective for persons who are motivated and involved in their treatment program. It is not as useful in maintaining abstinence after withdrawal from opiate drugs has been achieved (Greenstein, Fudala & O'Brien, 1992; Thomason & Dilts, 1991).

LAAM (levo-alpha-acetyl-methadol) is an experimental synthetic opiate that produces morphine-like effects. It is longer acting than methadone, allowing for doses to be administered only three times per week. It has not yet been approved in the United States for treatment of opiate dependence (Greenstein, Fudala, & O'Brien, 1992; Thomason & Dilts, 1991).

Antagonists

These drugs occupy the same receptor sites in the brain as specific drugs of abuse. However, they do not produce the same effects as the abused drugs, and they are non-addicting. Thus, when they are present, the effects of the abused drug are blocked because they cannot act on the brain in the usual way. Therefore, they do not produce the expected mood-altering experiences. Antagonists may be used for persons who do not want to be maintained on drug substitutes (i.e., agonists, like methadone); they also are used, at times, for persons leaving other drug-free treatment programs and re-entering the community, to diminish their risk of relapse (Greenstein, Fudala & O'Brien, 1992).

Naltrexone is an opiate antagonist, but experimental use with alcohol addiction has also been initiated. It does not result in euphoria as do opiate drugs (Alterman, O'Brien & McLellan, 1991; Greenstein, Fudala & O'Brien, 1992; Wesson & Ling, 1991).

Buprenorphine is a mixed agonist-antagonist agent. It is long-acting and blocks the effects of other opiate drugs. It produces less physical dependence than methadone, but some withdrawal symptoms do occur with its use (Greenstein, Fudala & O'Brien, 1992; Thomason & Dilts, 1991).

Antidipsotropics

These drugs create adverse physical reactions when the person consumes the substance of abuse. These drugs are used to develop an aversion to the abused drug (Alterman, O'Brien & McLellan, 1991).

Antabuse (disulfiram) interferes with the metabolism of alcohol, causing unpleasant side effects when alcohol is ingested. Facial flushing, heart palpitations and a rapid heart rate, difficulty in breathing, nausea, vomiting, and possibly a serious drop in blood pressure are the major effects produced by the combination of alcohol and Antabuse. Paired with other treatment approaches, Antabuse has been successful in preventing relapse (Alter-man, O'Brien & McLellan, 1991; Doweiko, 1990).

Psychotropic Medications

These control various symptoms associated with drug use and withdrawal. Antianxiety drugs, antipsychotics, antidepressants (for major depressions), and lithium have been tested. However, further research is needed on the effectiveness of these agents, as current research has produced conflicting results in some cases or has been inconclusive (Alterman, O'Brien & McLellan, 1991; Wesson & Ling, 1991).

Wesson and Ling (1991) conceptualize two categories of therapeutic medications. Those that help patients stop abusing drugs include medications that reduce acute drug withdrawal symptoms, medically maintain patients, decrease drug craving, and block the drugs' reinforcing effects. Methadone, clonidine, buprenorphine, LAAM, desipramine, bromocriptine, and naltrexone are included in this category. Medications that help prevent relapse are able to reduce prolonged withdrawal syndromes, decrease drug craving, alter the drug's reinforcing effects, treat underlying psychopathology, and treat drug-induced psychopathology. Included in this category are antidepressants, desipramine, bromocriptine, naltrexone, and disulfiram.

Most research and development of medications used in the treatment of addictive diseases has been fostered by the federal government. In treating most diseases, clinical trials of new medications usually are undertaken by pharmaceutical companies. However, these companies have been reluctant to associate their organizations and medications with drug addiction. This is, in part, due to the negative stereotypes of drug abusers. The number of persons who could benefit from a particular pharmacological treatment for addiction is also comparatively small. Thus, if involved in developing medications for addictive disorders, the pharmaceutical industry would not realize the degree of profit or recover its investment for research and development to the extent desired. There is also concern that medications will be diverted for street use or will be used in combination with other illegal drugs. Pharmaceutical companies worry that the drugs or their companies will gain a bad reputation if this occurs (Wesson & Ling, 1991).

Acupuncture and Transcutaneous Electrical Nerve Stimulation

Acupuncture applies a treatment method developed in China and other Far Eastern countries to the problem of alcohol and drug addiction. Addiction represents an adaptation of the central nervous system's activity in response to chronic drug administration, resulting in withdrawal symptoms when drug use is discontinued. Acupuncture or transcutaneous electrical nerve stimulation can modulate central nervous system activity in those regions of the brain affected by substances of abuse (Katims, Ng & Lowinson, 1992). Therefore, acupuncture may serve as a useful adjunct to comprehensive treatment for addiction.

Acupuncture involves placing needles at strategic body points (usually the outer ear). The treatments generally last for 45 minutes and are administered daily for the first few weeks and then are decreased. It is most commonly used to help drug users detoxify. The effect is a reported reduction in withdrawal symptoms and the physical craving for drugs and alcohol. Ideally, acupuncture treatment is combined with a comprehensive treatment approach, including counseling, drug testing and other interventions. Two significant advantages of this approach, at least in some programs, are its low cost and lack of waiting lists. Transcutaneous electrical nerve stimulation produces similar results but uses a different technology. Both therapeutic techniques can provide physiologic relief without toxicity or the potential for abuse that may be inherent in the use of medications (Bullock, Umen, Culliton & Olander, 1987; Chan, 1991; Katims, Ng & Lowinson, 1992; Singer, 1992).

Although still considered experimental, some limited research results have indicated benefits to patients with this form of therapy. In one controlled study, a group of alcoholics receiving acupuncture had significant continued treatment effects at the end of a six-month period. The control group, which received "sham" acupuncture (needles were put near but not on specified acupuncture sites), expressed moderate to strong desires to abuse alcohol (Singer, 1992).

Residential or Inpatient Treatment Programs

Programs in which the individual lives in the facility while participating in treatment can be defined as inpatient or residential programs. Some detoxification programs as well as therapeutic communities, and hospital-based programs are in this category. These programs are most appropriate for individuals who have not been successful in outpatient settings, those who have a very serious substance abuse problem, those needing concomitant medical or psychiatric care or observation, and those without a stable social support system in the community. Inpatient programs are the most restrictive, structured, and protective types of programs (Doweiko, 1990).

Inpatient Hospital Treatment

Inpatient treatment programs may be located in hospitals or in specialized chemical dependency centers. Chemical dependency treatment, Minnesota Model, 28-day programs, or Hazelden-type treatment are terms that may be used to denote this type of treatment approach. Many of these programs are privately financed; thus, patients are usually employed persons (or have employed spouses or parents) with private insurance. The goal of treatment is abstinence from alcohol or other drugs (Institute of Medicine, 1990).

A variety of treatment techniques and strategies are usually employed in these programs, including the Twelve-Step model (the basis of Alcoholics Anonymous and other self-help programs), individual, group and family counseling, drug education, and medical management. Long-term aftercare and transitional services, especially for opiate addicts, are an important part of treatment, but many programs do not devote significant resources to them (Doweiko, 1990; Institute of Medicine, 1990). These programs may be especially appropriate for persons with concomitant psychiatric disorders, persons assessed to be suicidal, those addicted to more than one chemical, or persons with serious medical complications. Inpatient treatment provides comprehensive treatment services, constant support during the early stages of sobriety, and close supervision to prevent relapse and respond to medical emergencies. Most inpatient programs have a multidisciplinary staff team, representing a range of training and experience and capable of offering a variety of services (Doweiko, 1990).

Several studies have consistently found that chemical dependency (inpatient) treatment is more effective for persons with alcohol addiction than for those whose presenting problem is another drug addiction. Those addicted to more than one substance (polydrug users) have the poorest prognosis (Institute of Medicine, 1990).

Therapeutic Communities

Therapeutic communities are self-contained residential programs that emphasize self-help and rely heavily on ex-addicts as peer counselors, administrators, and role models. They provide a highly structured milieu, with program stages through which members must progress; this advancement is noted with special tasks and ceremonies. The stages progressively demand more responsibility and provide more freedom. Group encounter sessions often are confrontational, focusing on openness and honesty. Social and vocational skills also are taught.

The goals of therapeutic communities include (Institute of Medicine, 1990):

• habilitation or rehabilitation of the total individual;
• changing negative patterns of behavior, thinking, and feeling that predispose drug use; and
• development of a drug-free lifestyle.

Because of costs, availability, and insurance reimbursement, several adaptations of the therapeutic community model have been developed (Singer, 1992). These include:

• Modified therapeutic communities, where stays last an average of six to nine months. The goals of treatment are more limited, but the primary objective is to help residents achieve a drug-free state and acquire practical living skills. This model is appropriate for persons with minimal social support systems (Singer, 1992).
• Short-term therapeutic communities, where residents remain an average of three to six months. The primary goal of this approach is to help persons attain a drug-free lifestyle; much less emphasis is placed on re-socialization. This model is appropriate for persons from a stable social and family environment (Singer, 1992).
• Adolescent therapeutic communities for juveniles. Modifications needed for youth include: increased supervision to prevent youth from leaving the program or engaging in antisocial behavior and negative peer activities; more recreational activities to promote leisure skill-building and prevent boredom; greater family involvement; academic education; increased staff-to-youth ratio; separation of youth by gender except for occasional program activities; and limiting the size of the program to 45 or fewer youth (Mullen, Arbiter & Glider, 1991).
• Therapeutic communities in correctional facilities to begin the treatment process in jails and prisons. These focus on socialization, positive value formation, and education. When released, inmates are referred to other treatment agencies in the community. This approach attempts to form a strong, positive, anti-drug culture; develop work teams; and provide referral and transitional services. Successful programs must have good working relationships between treatment and correctional personnel (Arbiter, 1988).

This modality has been considered appropriate for hard-core drug users involved in criminal activities. The treatment approach is not specific to any particular class of drugs. Individuals dependent on any illicitly obtained drug or combination of drugs are accepted in therapeutic communities. Characteristically, participants in therapeutic communities have experienced problems with social adjustment to conventional family and occupational responsibilities because of drug seeking (and, in some cases, before initiating drug use). Therapeutic communities often are seen as a next step for persons who continue to relapse in less restrictive treatment settings (Institute of Medicine, 1990; Thomason & Dilts, 1991).

Because of these programs' use of confrontation and prohibition of psychotropic drugs, the use of therapeutic communities is not appropriate for individuals with psychopathology or with substance abuse-related neurological damage. For some persons, especially those who have low levels of self-esteem and impaired neurological functioning, the confrontational approach of the modality may be too intense (Singer, 1992).

The length of stay in traditional therapeutic communities ranges from 6 to 24 months (ONDCP, 1990). Research has shown that the longer clients remain in therapeutic communities, the more likely they are to have positive results. However, traditionally, dropout rates are high. Approximately 15 to 25 percent of those admitted to therapeutic communities complete the program and graduate. About 25 percent drop out within two weeks, and about 40 percent, by three months (Alterman, O'Brien & McLellan, 1991; Institute of Medicine, 1990).

One study found that early dropouts from long-term therapeutic communities had common psychosocial characteristics, including (O'Brien & Biase, 1992):

• low self-esteem and self-value;
• poor concept of self-identity;
• low self-acceptance;
• low evaluation of self-behaviors;
• low evaluation of physical attributes, health, and sexuality;
• low assessment of self-worth and self-adequacy;
• low evaluation of self in relation to family/friends and primary group;
• high levels of self-criticism and lack of adequate defenses; and
• a tendency to overemphasize negative features.

Evaluations of therapeutic communities demonstrate that they are cost-effective when compared with prisons. While persons are in the program, criminal activity is significantly reduced compared with pre- or post-treatment criminal activity. For those who complete the program, illicit drug use and criminal activities are diminished, while employment status improves (Institute of Medicine, 1990; Singer, 1992). Approximately 15 percent of therapeutic community graduates qualify to be trained for staff counseling positions. Of those, approximately half continue their employment for more than one year (O'Brien & Biase, 1992).

Some studies have reported that less severe criminal activity is correlated with longer retention in therapeutic community programs, while lower lifetime criminality has been correlated with better treatment outcomes. More positive treatment outcomes have also been noted with higher levels of education and lower levels of drug and alcohol use (Singer, 1992).

Outpatient Nonmethadone Treatment

Outpatient nonmethadone treatment programs involve trained professionals working with addicted persons to achieve and maintain abstinence while living in the community. Community mental health centers, private clinics, and professional therapists in private practice are examples of settings in which outpatient treatment is offered. Outpatient treatment programs offer a range of services and treatment modalities, including pharmacotherapy, and individual, group, and family counseling. They often incorporate a Twelve-Step philosophy (Doweiko, 1990).

Outpatient treatment allows individuals to live at home, continue working, and be involved in family activities while receiving treatment. Outpatient treatment is usually less expensive than residential treatment alternatives. It also allows for longer-term support of the individual than is possible with inpatient programs (Doweiko, 1990).

Considerations for referring individuals to outpatient treatment programs include their motivation for treatment, ability to discontinue use of drugs or alcohol, social support system, employment situation, medical condition, psychiatric status, and past treatment history (Doweiko, 1990). Those who remain in outpatient (nonmethadone) treatment longer tend to have better outcomes than shorter-term clients. However, dropout rates are high (Institute of Medicine, 1990).

Combined Settings

Some treatment programs have been developed to attempt to capitalize on the advantages of both inpatient and outpatient treatment approaches. They provide elements from each type of setting, attempting to maximize benefits while reducing costs.

Two by Four Programs are two-phase approaches. The individual is hospitalized first for a short time (usually two weeks). This ensures complete detoxification. This is followed by outpatient treatment. However, there is the option to return to inpatient care if he or she is unable to function in the less restrictive outpatient program (Doweiko, 1990).

Day or partial hospitalization involves treatment in the program during normal working hours, but the person returns home during the evening hours. The individual lives at home and has to assume more responsibility than would be the case in inpatient treatment. A prerequisite for this type of treatment is a supportive, stable family (Doweiko, 1990).

Halfway houses provide an intermediate step between inpatient treatment and independent living. It is a good alternative for persons who do not have a stable social support system. Halfway house programs generally have a small patient population, emphasize Twelve-Step programs, and have a minimum of rules and few professional staff members. Usually residents must find employment or work within the house (Doweiko, 1990).

As with other treatment programs, length of stay for some subgroups of residents has been correlated with successful treatment outcomes. Other evaluations of effectiveness have been contradictory, however (Doweiko, 1990).

Treatment Components

A variety of techniques are used in all the treatment modalities just presented. These include self-help or Twelve-Step approaches; individual, group, and family counseling; and behavior modification approaches. Each of these will be discussed briefly.

Self-Help Programs

Self-help or Twelve-Step organizations involve mutual help among peers experiencing similar problems. With the development of the first Alcoholics Anonymous group in 1935, a long tradition of the use of self-help groups for sub-stance abusers was launched. Self-help groups often meet in churches, community facilities, prisons, and other locations, but they generally claim no political or religious affiliation. Alcoholics Anonymous (AA) describes itself as a voluntary, self-run fellowship. Its membership is multiracial and there are no age, educational, or other requirements for members. It is nonprofessional and has no dues or outside funding sources. An important characteristic for many persons is its promise of anonymity, protecting the right to privacy of its members (Doweiko, 1990; Nace, 1992).

Members of AA believe that addiction is a disease that can never be cured. However, they maintain that progression of the disease can be arrested, and those in remission are recovering alcoholics (Doweiko, 1990). Groups function to reinforce social and cognitive behaviors that are incompatible with addictive behaviors. The Twelve Steps provide a concrete, tangible course of action (Galanter, Castaneda & Franco, 1991; Nace, 1992).

The primary goals of AA and similar self-help groups are to (Galanter, Castaneda & Franco, 1991):

• achieve total abstinence from alcohol or other drugs;
• effect changes in personal values and interpersonal behavior; and
• continue participation in the fellowship to both give and receive help from others with similar problems.

Self-help groups may be the only intervention used by some persons to end chemical dependency. However, self-help groups often are used in tandem with other treatment modalities, such as residential or outpatient treatment programs.

Alcoholics Anonymous developed the Twelve-Step tradition that has been adopted and adapted by many other self-help groups. These steps consist of a series of cognitive, behavioral, and spiritual tasks, including (Doweiko, 1990):

• an admission of powerlessness;
• assessment of character defects;
• overcoming shortcomings that contributed to addiction, learning the tools of nondrug-centered living, and restructuring damaged relationships; and
• commitment to a higher power.

Often, experienced members act as "sponsors" to newer members, creating a person-to-person guidance system in times of crisis and creating bonds between members (Nace, 1992).

AA groups are autonomous and traditionally are open to all members. Some groups may be directed to special-interest groups, such as women, minority groups, gays, or physicians (Galanter, Castaneda, & Franco, 1991; Nace, 1992). There are several types of meetings (Nace, 1992).

• Closed meetings are for AA members or prospective members only.
• Open meetings are for non-alcoholics as well.
• Speaker meetings involve AA members who describe their experiences with alcohol and their recovery.
• Discussion meetings are those in which an AA member describes personal experiences and leads a discussion on a topic related to recovery.
• Step meetings (usually closed) consist of discussion of one of the Twelve Steps.

The self-help approach was first applied to drug addiction in the U.S. Public Health Service Hospital in Lexington, Kentucky, in 1947. Narcotics Anonymous (NA) is modeled on the Alcoholics Anonymous concept, and although the two programs are not affiliated, they use the same Twelve-Step program. NA is a different organization with diverse jargon, style, substance, and social traditions. It is concerned with the problem of addiction, and members may have had experience with any or all of the entire range of abusable psychoactive substances. (Doweiko, 1990; Galanter, Castaneda & Franco, 1991; Gifford, 1989). Thus, referrals to the two organizations should be made with care. Alcoholics Anonymous focuses on alcohol dependence and behaviors, while Narcotics Anonymous focuses on drug addictions and uses drug-specific language and approaches. Narcotics Anonymous developed more recently and reflects the milieu of the late 1970s and 1980s, according to Gifford (1989). He believes this makes it a more applicable organization for the needs of many drug-involved persons.

Alcoholics Anonymous is now a world wide organization with groups in the United States and 114 other countries. Its membership is estimated at 1.5 million. Narcotics Anonymous is international as well, with groups in at least 36 countries. Estimates of its membership total approximately 250,000 (Galanter, Castaneda & Franco, 1991).

Although there is ample anecdotal testimony to the effectiveness of self-help organizations, especially Alcoholics Anonymous, there is little in the way of objective data to support these claims. However, opinions of many clinicians and individuals who have been helped by the approach strongly support it for the recovery for some substance abusers. Scientific research of these groups is very difficult because of the anonymity promised to members and self-selective membership practices. It is difficult to arrange studies with appropriate sampling techniques, control groups, or experimental design (Galanter, Castaneda & Franco, 1991; Nace, 1992).

Emrick (1987) reviewed several studies of the outcomes for persons attending AA and found that, overall, 46.5 to 62 percent of active AA members had at least one year of continuous sobriety. Thirty-five to forty percent of subjects reported abstinence of less than one year. Twenty-six to forty percent were sober from one to five or six years, and 20 to 30 percent maintained abstinence five or six years or more.

Self-help or Twelve-Step programs may be useful adjuncts to treatment for alcohol and other drug abuse. Persons who attend AA and other treatment programs have a more favorable outcome in regard to drinking. Those who attend more than one meeting per week, have a sponsor and/or sponsor others, lead meetings, and work Steps 6 through 12 tend to have more favorable outcomes (Geller, 1992; Nace, 1992).

Individual Counseling

Individual counseling approaches assume a one-to-one encounter between a client and a counselor. Counselors are usually trained professionals, but they may be paraprofessional or peer counselors. The specific counseling approach or methods used in individual treatment of substance abusers come from modalities originally developed to treat other conditions. Regardless of the particular counseling model endorsed, there are some tasks or goals of individual treatment that usually are seen across all approaches, although the emphasis placed on each may vary. These include (Rounsaville & Carroll, 1992):

• helping the individual resolve to stop using psychoactive substances;
• teaching coping skills to help the person avoid relapse after achieving an initial period of abstinence;
• changing reinforcement contingencies;
• fostering management of painful feelings; and
• improving interpersonal functioning and enhancing social supports.

Substance abusers typically enter treatment with a goal of controlled use, especially of alcohol. Therapists help patients explore their motivation and set appropriate treatment goals, including a goal of abstinence. Identifying circumstances that increase the likelihood of resuming drug use and practicing strategies for coping with these high risk situations are other parts of the treatment process. For many substance abusers, drug use has been the entire focus of their lives. When it stops, they need help in filling their time and finding rewards that replace those derived from drug use. Many drug-involved persons have never achieved satisfactory adult relationships or vocational skills because drug abuse was initiated during adolescent or early adult years. Individual interventions can help them maintain their motivation during the processes of learning new skills and recovery. Individual therapy often includes techniques to elicit strong feelings and help the individual learn acceptable means of managing them within the protected environment of the therapeutic setting. For some persons who have emotional or anxiety disorders, combined treatment with medications and individual counseling may be appropriate. Encouraging the person to participate in self-help groups can provide a source of social support outside of individual counseling sessions (Rounsaville & Carroll, 1992).

Individual therapy provides privacy to those persons who are not willing to disclose their substance abuse publicly or fear that doing so may damage their careers and reputations. In individual treatment, the pace can be flexible to meet the needs of the individual. Compared to group therapy, much more time can be spent on issues that are unique to the individual involved. In situations where caseloads are not large enough to have appropriate groups, individual therapy is more practical and can begin immediately. Some patients have particular personality disorders that do not lend themselves to group involvement (Rounsaville & Carroll, 1992).

Individual therapy is more expensive than group therapy because of the one-to-one relationship of the therapist and patient. Involvement in group treatment approaches also can have the advantage of mutual support and modeling of coping strategies. Group members often provide external control for an individual, as they may be able to detect each other's attempts to conceal relapse or early warning signals that relapse is beginning (Rounsaville & Carroll, 1992).

Rounsaville and Carroll (1992) reviewed several empirical studies of individual treatment of drug abusers and reached the following conclusions:

• Most studies indicate that persons involved in individual treatment, either as a single modality or in combination with other approaches, do better than those in control groups (not receiving individual treatment).
• No specific type of individual treatment approach has been shown consistently to produce better results.
• Individual treatment is especially appropriate and effective for persons with other psychiatric problems.

Group Therapy

Group therapy is often combined with other treatment modalities to provide a structured, comprehensive treatment program for substance abusers. Washton (1992, p. 508) defines group therapy as:

. . . an assembly of chemically dependent patients, usually five to ten in number, who meet regularly (usually at least once a week) under the guidance of a professional leader (usually a professional therapist or addiction counselor) for the purpose of promoting abstinence from all mood-altering chemicals and recovery from addiction.

The treatment goals of group therapy may include (Washton, 1992):

• establishing abstinence;
• integration of the individual into the group;
• stabilization of individual functioning;
• relapse prevention; and
• identifying and working through long-standing problems that have been obscured or exacerbated by substance abuse.

Galanter, Castaneda, and Franco (1991) have identified several types of group approaches used with alcohol- and drug-involved persons. These include the following categories.

Exploratory groups explore and interpret members' feelings and help them develop greater ability to tolerate distressing feelings without resorting to mood-altering substances.

Supportive groups help addicted members tolerate abstinence and assist them in remaining drug- or alcohol-free by enabling them to draw on their own resources.

Interactional groups create an environment of safety, cohesion, and trust, where members engage in in-depth self-disclosure and affective expression.

Interpersonal problem-solving groups teach an approach to solving interpersonal problems, including recognizing that a problem exists, defining the problem, generating possible solutions, and selecting the best alternative.

Educational groups provide information on issues related to specific addictions, such as the natural course and medical consequences, implications of intravenous drug use, and availability of community resource. Methods used may include material such as videotapes, audio cassettes, or lectures followed by discussion.

Activity groups provide occupational and recreational means for socialization and self-expression.

Groups are often an especially important aspect of treatment for youth, as peer associations are particularly important during adolescence. Their developmental tasks include separating from family and forming their own identities. Peer groups have a significant effect on attitudes and behavior. This influence can be either positive or negative. Peer groups may be located in schools, community agencies, residential programs, and churches and on the streets (such as gangs). Four categories of peer group programs have been identified by Resnik and Gibbs (1988):

1. Positive peer influence programs emphasize group interaction and positive influence of the group on the individual member.
2. Peer teaching programs emphasize youth conveying information to their peers.
3. Peer counseling, facilitating, and helping programs focus on peers helping peers. Through these programs, youth who provide help develop a sense of responsibility. The "helper" often benefits more than the peer who is helped.
4. Peer participation programs create new roles for youth, giving them decision-making power and responsibility. These programs emphasize youth empowerment and accountability.

Despite the persistent use and popularity of group treatment approaches, few studies of effectiveness have been done. Some advantages of group therapy include its cost-effectiveness, allowing one professional to work with several different individuals at once; shared learning among group members; and the potential to work through problems from earlier stages of growth because group members may reflect characteristics of a member's family of origin (Doweiko, 1990).

Family Therapy

In many cases addictive disorders are multigenerational within families. A full assessment of the identified substance abuser and his or her family is important to determine the range of biopsychosocial factors influencing the person's addiction. Within family systems drug use behavior has a purpose, and it is important to assess this. Family therapy is usually not sufficient as the sole means of treatment for substance abuse. Rather, it is a valuable, and often essential, adjunct to other treatment modalities. The opportunity to observe the total family is always valuable in the diagnostic process (Doweiko, 1990; Kaufman, 1992).

There are three parts of the family system (often traversing three or more generations) that are important to include, if applicable and available. These include the substance abuser's family of origin, spouse, and children. At times it can be helpful to broaden the definition of family to include significant others and employers (Kaufman, 1992).

The dysfunctional patterns manifested by families of substance abusers may include denial of the problem, scapegoating all family problems on the identified abuser, the use of guilt by the addict to coerce the family into supporting his or her habit, negative communication, and lack of consistent limit setting by parents. Children of alcoholics are more likely to develop emotional and psychosocial problems, including substance abuse. Adult children of alcoholics tend to have poor communication skills, difficulty expressing feelings, role and identity confusion, and problems with trust and intimacy. Approximately 30 percent of children from alcoholic families marry alcoholics. Alcoholic fathers are apt to abuse their children through violence, sexual seduction, or assault, and alcoholic mothers are more likely to neglect their children (Kaufman, 1992).

Family treatment priorities include persuading the family to work together to initiate detoxification of the identified person. Also important is helping the family initiate and support the person's involvement in an appropriate treatment program (e.g., Twelve Steps, therapeutic community, methadone maintenance). Family members may need to be coached by the therapist to confront the addicted person with care and concern. The family also may need to be educated about the deadly consequences of substance abuse, and they may need help in setting limits. Behavior techniques may be used to eliminate family members' responses that trigger drug use; in their place, methods of reinforcing positive behavior may need to be taught. Communication-centered therapy may be needed to teach people to state messages clearly and correct discrepancies in communication among family members (Kaufman, 1992).

As juveniles are not yet independent, family interventions are especially important in addressing the basis of their drug and alcohol involvement. Some juveniles may not be living with their families of origin, but may be in adoptive families, foster family placements, or other family surrogate situations. Regardless of the definition of family used, involving those who are significant in the youth's life is important. Family interventions may include classes to help parents, siblings, and others understand substance abuse. Both educational and counseling interventions to improve coping and parenting skills may be beneficial (MacDonald, 1989).

Although continuing research efforts are needed, available data do support the efficacy of family therapy interventions. Adolescents involved in family therapy have been shown to have half the recidivism rate of those not receiving this service. There is also evidence that family therapy improves adolescent retention in residential treatment programs. Family treatment has also been favorably correlated with days free of methadone, illegal opiates, and marijuana. McCrady et al. (1986) found that alcoholic persons who received treatment with their spouses, including both alcohol-related interventions and marital therapy, were more compliant, decreased their drinking more rapidly, and relapsed more slowly than study participants who received only alcohol-focused treatment with their spouses. They also maintained better marital satisfaction and were more likely to stay in treatment than persons receiving treatment with minimal spouse involvement. In general, family involvement enhances assessment and intervention and increases motivation in treatment (Kaufman, 1992).

Behavior Modification

Behavior modification is often incorporated in various treatment modalities. Behavior modification increases rewards for positive, pro-social behavior. Rewards may include praise, attention, activities, and material items. For negative or antisocial behavior, responses that are unpleasant or withhold rewards may help to extinguish the unwanted behavior. Programs that gradually give participants increased freedom as they show responsibility are using positive rewards. Some programs have levels, steps, or phases that participants must earn through appropriate behavior. With each advancement there are rewards of privileges, increased freedom, and decreased supervision.

Aversive Conditioning

Aversive conditioning is an example of providing negative rewards to extinguish unwanted behaviors. Unpleasant stimuli, such as chemically or hypnotically induced nausea or paralysis, electrical shock, and noxious imagery, are paired with the sight, smell, and taste of the abused drug. When the person has contact with the abused substance, the same response is triggered and he or she experiences repulsion instead of craving or the desire to use the drug (Childress, Ehrman, Rohsenow, Robbins & O'Brien, 1992; Goodwin, 1992).

Programs using this approach have claimed high rates of success. However, research studies often have been flawed, and follow-up studies have found inconsistent results. Additional studies are underway to assess the usefulness of this approach (Childress, Ehrman, Rohsenow, Robbins & O'Brien, 1992; Goodwin, 1992).

Conclusion

In this chapter both the causes of substance abuse and current treatment approaches have been reviewed. One's point of reference concerning the causes of addiction often influences decisions about treatment practices.

Addiction to alcohol and other drugs is multifaceted. For most people there is not a single cause of addiction; rather, there is a complex set of biological, social, and psychological influences that contribute to the initiation of substance use and progression to addiction. The combination of causal factors is unique for each person. Treatment programs also have particular philosophies about addiction. Thus, a comprehensive assessment is required to identify the causes of each individual's addiction and plan for appropriate patient-treatment matching. Treatment is likely to be more effective when program philosophies are considered in comparison to an individual's specific needs and characteristics. The next chapter, Screening and Assessment, and Chapter 5 on patient-treatment matching will address these topics in greater detail.

Substance abuse treatment occurs in a variety of settings under the auspices of various agencies and organizations. Both the treatment modality and the treatment setting are important considerations. Some individuals will be more successful with the restrictions of a residential setting while others may do well in outpatient treatment. Pharmacotherapy has been proven effective for treating some drug addiction problems. Other chapters will describe more fully some of the treatment modalities summarized in this chapter.

Relapse prevention programming, another critical element of treatment, has been emphasized through the information provided about treatment effectiveness of each modality. Rates of relapse for most current treatment modalities are high, and increased attention to relapse prevention is needed to mitigate this trend. This topic will be discussed further in Chapter 9. Finally, the meager evaluation studies of many treatment modalities emphasize the need for continuing research and greater program accountability, the fifth critical element. More information about this area is provided in Chapter 10.

In the continuing quest to discover ways to change the behavior of drug-involved persons and help them achieve better health and well-being, current approaches can be improved and new approaches should be sought to enhance drug abuse treatment. Coordination among all systems that interact to provide and promote treatment is of vital importance. Treatment providers and local, State, and federal decision makers can have a significant impact on the future role of treatment. Solutions to many of the problems related to alcohol and drug addiction are possible, and treatment is an important part of the response.

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Last Updated 11-7-02