What is alcohol and other drug (AOD) addiction? It is a chronic, progressive, pathologic process that typically includes compulsion to use or reuse AODs, loss of control over AOD use, and continued AOD use despite adverse consequences.
The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994) enumerates diagnostic criteria for substance dependence -- the term used by the American Psychiatric Association to describe AOD addiction (see Exhibit 2-1). According to the DSM-IV, a diagnosis of substance dependence requires the presence of three or more of these criteria at any time in the same 12-month period. Tolerance, physiological dependence, and withdrawal are not necessary to establish a diagnosis of AOD addiction.
Addiction is a biopsychosocial process. The onset, progression, type, and severity of addiction are influenced by biological, psychological, and social factors; in turn, addiction has a profound impact upon the individual's biological, psychological, and social functioning. For these reasons, AOD treatment should be biopsychosocial in nature. In a biopsychosocial orientation, the focus of treatment will shift from one area to another depending upon the patient's status and treatment needs. For example, the early stages of AOD treatment may focus on pharmacologic management of medical and psychiatric crises. As treatment progresses and these crises fade, other biopsychosocial factors can be addressed in such activities as individual or family counseling.
AOD addiction treatment was traditionally designed on a standardized model that began with inpatient hospitalization for detoxification (medically supervised withdrawal) and rehabilitation for 30, 45, or 60 days. This model was adopted by healthcare facilities because insurance companies paid for care, using criteria based on this model. Outpatient AOD treatment -- lasting from several months to 1 or more years -- traditionally followed the inpatient hospitalization.
Today, AOD treatment often begins with an assessment of the level of treatment intensity required to meet an individual patient's needs, which may or may not include hospitalization. As patients successfully meet their treatment goals, they proceed to less intensive levels of care.
There are three primary levels of care: inpatient, intensive outpatient, and outpatient treatment. Inpatient treatment includes short-term and long-term hospitalization. Intensive outpatient treatment includes partial hospitalization, day programs, and evening programs. Outpatient treatment generally involves a set number of hours weekly. All three levels of care include such activities as group counseling or individual therapy; education; attention to medical, mental health, or social issues; and participation in 12-step programs.
AOD treatment and recovery services can be delivered in a variety of residential settings, including intensely supervised therapeutic communities; supervised group homes; and unsupervised, drug-free halfway houses.
AOD treatment options are greatly influenced by financial considerations. Increasingly, insurance payers and managed-care providers pay for AOD and psychiatric treatment on a day-by-day basis, with an emphasis on minimizing both the duration and the intensity of treatment.
The major source of funding for publicly funded AOD addiction treatment is the substance abuse State block grant, which is administered by the Center for Substance Abuse Treatment (CSAT), an agency of the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services.
Through the years, separate branches of Federal and State governments have provided distinct funding for alcohol treatment, drug abuse treatment, and mental health treatment. As a result, several types of publicly funded programs provide AOD abuse treatment in dissimilar settings for different types of patients, often using different treatment approaches and philosophies. Ideally, such a collection of public-sector programs would create a comprehensive treatment network capable of addressing detoxification, long-term treatment, and relapse prevention. In practice, although an extensive treatment network exists in many geographic areas, treatment services are fragmented and incomplete; in some areas services are inadequate.
Variants of treatment programs include special gender-specific and culture-specific programs, as well as programs for underserved groups such as single mothers, adolescents, families, gay men and lesbians, and people infected with the human immuno-deficiency virus (HIV). Depending on local resources, there may or may not be an extensive continuum of care in the public sector.
Overall, treatment settings differ with respect to duration, intensity, and setting. Treatment for an individual may involve multiple settings, either serially or simultaneously.
Outreach and prevention. The structure of medical services is such that people are generally required to seek medical care in order to receive it. Such an approach excludes people who are not seeking treatment, have poor insight about their AOD use, or are unaware of treatment resources. Many of these people may be at risk of contracting HIV infection as a result of the sexual disinhibition that accompanies AOD abuse. Community-based outreach workers can provide personal contact between the medical establishment and people requiring education, intervention, and treatment.
Some models of outreach and prevention focus directly on AOD prevention, intervention, and treatment, often in unconventional sites, such as inner-city hotels, recreational areas, and the street. Needle exchange programs, which provide clean needles and syringes to injection drug users in exchange for used ones, employ a harm reduction approach to reducing the risk of HIV infection from injection drug use. Most needle exchange programs also supply condoms and provide bleach for syringe disinfection; most programs selectively refer clients to AOD abuse treatment Lurie et al., 1993). (See Appendix C for information about needle exchange programs.)
Outpatient treatment traditionally involves only a few hours of treatment per week; it is the least intensive and restrictive level of care in addiction treatment. This level of treatment is most appropriate for people who are employed, have a stable and supportive social and family environment, recognize that their AOD use is a problem, and desire help for the problem. Outpatient programs provide no living facilities and usually have little medical supervision, although most of these "social model" programs are affiliated with one or more medical facilities and personnel. A variety of outpatient treatment models exist. They usually provide counseling, peer support, and social services referrals. Most incorporate the principles of abstinence-based 12-step programs such as Alcoholics Anonymous.
Intensive outpatient treatment (IOT) programs generally provide a few hours of treatment each day, often including weekends. For example, programs may provide 2 to 8 hours of treatment Monday through Friday and perhaps 2 to 8 hours each weekend. These programs may last 6 to 12 weeks or longer. Some programs offer treatment sessions in the evening and on weekends to allow people to continue working while participating in treatment.
As a higher level of care than outpatient treatment, IOT offers more structure and more hours of treatment per week. It can provide multiple treatment components in the same setting and allows for increased bonding among peers in treatment through group interaction. This bonding may facilitate a drug-free social network of friends who have sobriety as a central focus. The most common models of IOT include day treatment programs (partial hospitalization), evening treatment programs, and weekend treatment programs. (Another Treatment Improvement Protocol [TIP] in this series, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse, provides an extensive discussion to one approach to providing this level of care.)
Partial hospitalization or day treatment is a form of intensive outpatient treatment that lasts 5 to 8 hours per day, from 5 to 7 days per week. Partial hospitalization provides treatment similar to that found in the daytime portion of an inpatient program. It may combine partial hospitalization and dedicated residential living for patients, making possible intensive daytime treatment and regulated evening activities.
Evening treatment programs typically provide 2 or more hours of treatment several evenings per week. Weekend treatment programs typically provide 5 or more hours of treatment on Saturday and Sunday. In practice, IOT programs often include some combination of daytime, evening, and weekend treatment.
Inpatient treatment is the most intensive level of care for AOD abuse. It generally includes medical, psychiatric, and nursing care. Inpatient treatment is particularly valuable for medical and psychiatric evaluations, medical management of detoxification, and management of medical problems (related or unrelated to the addiction), as well as management of psychiatric crises. The enhanced accessibility of medical and psychiatric care in inpatient treatment is particularly valuable for the AOD treatment patient who needs medical care related to HIV infection and infectious diseases, such as the tuberculosis or sexually transmitted diseases that occur at a high rate among HIV-infected AOD abusers.
Residential treatment programs consist of a spectrum of live-in settings. The treatment philosophy may be an abstinence-based medical model with a 12-step program orientation. These programs are often approved and accredited by the Joint Commission on Accreditation of Health Care Organizations. Occasionally, these programs are hospital based, but most residential programs are freestanding. Treatment may last from 1 week (detoxification) to 28 days (rehabilitation) or even more. Often when treatment in this setting is completed, patients are referred to an outpatient program.
Social model residential treatment programs and halfway houses are other models of residential addiction treatment. The residence used exclusively for patients may be a house or apartment, often with a resident manager. In residential treatment, patients are often responsible for the normal activities of daily living. Programs are often designed so that patients obtain and prepare their own meals, do their own laundry, keep the residence clean, and set and observe house rules.
Therapeutic communities are residential treatment systems in which adults and older adolescents with long and severe histories of substance abuse are treated in a peer-based milieu. A behavioral relearning process that incorporates both positive reinforcement and negative sanctions is the principal treatment modality. Residents themselves provide some aspects of treatment as a requirement before they can leave the program. Treatment typically lasts between 18 and 36 months. Most therapeutic communities operate according to a rigid set of rules and norms. Health services are not always provided onsite.
Special treatment settings provide for addiction treatment at nontraditional sites, such as prisons and community-based programs for offenders on probation or parole, housing projects, homeless shelters, runaway shelters, community-based organizations, churches, and group homes. Some hospital-based HIV/AIDS treatment programs also provide a range of AOD treatment services.
Most injecting drug users (IDUs) are addicted to opioids. Opioid substitution therapy is the most common treatment for opioid addiction, especially in cities with high HIV seroprevalence. Formerly called methadone maintenance treatment, this approach now may include the use of levo-alpha-acetyl-methadol (LAAM), which is similar to methadone but has longer acting effects. Three other TIPs in this series provide a detailed overview of opioid substitution therapy: State Methadone Treatment Guidelines, Matching Treatment to Patient Needs in Opioid Substitution Therapy, and LAAM in the Treatment of Opiate Addiction.
Opioid substitution therapy has been proposed as the preferred method of treatment for the HIV-infected opioid user (Cooper, 1989;Ball et al., 1988;Batki, 1988) because it frequently involves daily attendance at a clinic that may offer access to medical care, psychiatric consultation and treatment, neuropsychological evaluation, and social services. Studies have demonstrated that opioid substitution therapy is associated with a reduced risk of contracting HIV and may prevent infection of those patients not yet exposed to the virus (Lowinson et al., 1992).
The principal use of opioid substitutes in the treatment of opioid addiction is in opioid substitution combined with either detoxification or maintenance. These modalities are found in both public and private settings.
Opioid detoxification (medically supervised withdrawal). The primary medical goal of opioid detoxification is to manage the acute opioid withdrawal syndrome. The pharmacologic objectives of opioid detoxification using methadone are substitution of the opioid of choice with pharmacologically equivalent doses of methadone, a period of pharmacologic stabilization, and incremental reduction of methadone.
Federal regulations describe two types of medically supervised withdrawal from opioids: short-term (up to 30 days) and long-term (30 to 180 days). (Regulations do not permit use of LAAM for either short- or long-term detoxification.) Assuming no consumption of opioids beyond the administered methadone, short-term opioid detoxification ends in an opioid-free state 30 days or less from commencement of opioid substitution therapy (often 21 days or less). Long-term opioid detoxification is currently the subject of demonstration projects and research efforts.
Opioid maintenance therapy. The primary medical goal of opioid maintenance is to substitute methadone or LAAM for heroin or other opioids. The primary pharmacologic objectives are substitution of the opioid of choice with equivalent doses of methadone or LAAM and continued administration of methadone or LAAM for a prolonged period measured in months or years. The administration of methadone or LAAM to treat opioid addiction for more than 30 days is considered maintenance.
Outpatient opioid treatment. Both detoxification and maintenance can occur in an outpatient setting. Outpatient treatment typically involves daily or near-daily visits by the patient to a dispensing clinic. Ideally, methadone or LAAM treatment is accompanied by supportive psychosocial services such as medical and psychiatric treatment, AOD counseling, and vocational counseling. In practice, there is great variability among programs: some provide minimal psychosocial support services while others provide a high level of psychosocial services.
Intensive outpatient treatment. This is an ideal level of care for patients needing detoxification or methadone/LAAM maintenance because intensive outpatient treatment programs can provide several types of psychosocial services. Studies show that opioid substitution therapy programs that provide medical and psychiatric care, social work assistance, family therapy, and employment counseling promote several positive outcomes, including improvements with regard to AOD use, criminal involvement, family relations, the need for emergency services, psychiatric status, and employment (McLellan et al., 1993).
Inpatient treatment. Opioid detoxification using methadone is commonly used in inpatient settings where the methadone dosage can be easily controlled and administered. Methadone/LAAM maintenance is uncommon in an inpatient AOD treatment setting. However, it is important that individuals receiving methadone/LAAM maintenance treatment continue to receive these medications while hospitalized for treatment of other medical conditions.
Range of approaches to opioid substitution therapy. Opioid treatment programs differ in the emphasis they place on supportive services and in their orientation toward abstinence. Many programs can be described as employing either the metabolic model or the psychotherapeutic model.
The metabolic model views opioid addiction primarily as a medical problem that can be treated pharmacologically with methadone/LAAM. Within this model, methadone or LAAM is viewed in much the same way as insulin for diabetes or antidepressants for clinical depression. Therefore, abstinence is not a primary treatment goal, and psychosocial services, especially psychotherapy, are viewed as adjuncts to methadone or LAAM (although such views are changing).
The psychotherapeutic model views opioid addiction as a biopsychosocial disorder that requires biopsychosocial treatment, of which methadone/LAAM is one element. In this model, psychosocial services are primary treatment services of at least equal importance to methadone or LAAM. Many programs based on a psychotherapeutic model view maintenance as a vehicle for enhancing psychosocial stabilization, with the goal being abstinence from all AODs.
Sometimes driven by one of the above models, and sometimes driven by other reasons (such as cost), maintenance programs vary greatly with regard to the intensity of services provided.
Minimum opioid maintenance programs generally provide methadone/LAAM and emergency counseling or referral services. One form of minimum maintenance is interim methadone/LAAM maintenance, which is described in Federal regulations 21 (C.F.R.) Part 291. Interim maintenance consists of dispensing methadone/LAAM in combination with education and counseling about HIV, tuberculosis (TB), and needle sharing for people who are on a waiting list for comprehensive methadone/LAAM maintenance treatment services.
Standard opioid maintenance programs generally provide supervised counseling and referral services and use weekly urine screens as the basis for patient management. For example, permitting patients to have "take-home" methadone doses is usually contingent on attendance, negative urine samples, and verifiable employment. (Federal regulations do not permit take-home doses of LAAM.)
Enhanced opioid maintenance programs provide all of the above-mentioned services in addition to medical and psychiatric care, social work assistance, family therapy, and employment counseling. One recent study found that treatment outcomes improved with the provision of enhanced services (McLellan et al., 1993).
Treatment programs for AOD addiction vary in style, purpose, philosophy, and type of patients treated. Certain components of treatment, however, are common to all models of treatment programs. The components of CSAT's model comprehensive AOD treatment program are described in Exhibit 2-2.
The treatment of AOD addiction often begins with the management of medical and psychiatric crises. The medical management of toxicity, withdrawal, and other medical sequelae of AOD use is initially important.
The management of toxicity includes emergency medical interventions in response to AOD overdose. Opioid overdose may be treated with an opioid antagonist such as naloxone (Narcan). A benzodiazepine may be administered to quell symptoms of cocaine overdose, such as severe agitation, belligerence, and anxiety.
Management of AOD withdrawal may include substitution therapy with graded reduction of methadone (for opiate addicts) or sedative-hypnotics (for sedative-hypnotic addicts). Medication may also be given for withdrawal symptoms: Clonidine may be given for opioid withdrawal and bromocriptine or amantadine for cocaine withdrawal.
Management of other sequelae of AOD use may include preventing and treating seizure disorder and delirium tremens associated with alcohol abuse, treating infections secondary to needle use, and replacing electrolytes to correct nutritional deficiencies induced by alcohol abuse.
Acute medical problems unrelated to AOD use may also require attention. Since people with AOD problems often ignore general health problems, such problems may be exacerbated. By the time an individual seeks treatment for an AOD problem, other previously ignored health conditions may have progressed to a late stage.
Management of acute psychiatric crises may also be necessary. People who enter AOD treatment often do so in the context of emotional upheaval and family distress. In addition, it is not uncommon for AOD abusers to display psychiatric symptoms such as depression, anxiety, agitation, or disordered thinking. Such patients may require psychiatric assessment and a combination of pharmacologic and psychosocial supportive therapy. (See Chapter 4 for a detailed discussion of the mental health needs of HIV-infected AOD abusers.)
During and after stabilization of crises, patients are assessed to determine their level of functioning in the following areas: medical, psychiatric, emotional, social, family, vocational, legal, nutritional, and recreational. These evaluations form the basis for individualized treatment plans that guide the treatment process, establish treatment goals, and enable the measurement of treatment success.
As patients become engaged in treatment and as medical and psychiatric crises lessen in intensity, treatment becomes progressively more psychosocial. Overall AOD abuse treatment goals are met through a variety of treatment components, including education, group processes, 12-step programs, self-help programs, therapy, and counseling. (See Chapter 4 for a discussion of the role of such programs in the treatment of HIV-infected AOD abusers.)
The use of methadone for detoxification and methadone and LAAM for maintenance therapy is described above. Two other medications may be used as adjuncts to AOD treatment and recovery: naltrexone (Trexan) and disulfiram (Antabuse).
Although there are fundamental differences between these two medications with regard to pharmacologic activity and purposes, naltrexone and disulfiram share certain clinical similarities. For example, both agents are used to diminish the likelihood of impulsive AOD use. Both are more likely to be prescribed during the continuing-care stage of AOD abuse treatment. Finally, both are considered pharmacologic adjuncts to AOD treatment. That is, used in isolation, they are unlikely to be successful; however, used in the context of a full recovery program, they can provide short-term treatment enhancement.
Disulfiram is an alcohol-sensitizing medication; it produces unpleasant symptoms if the person taking it also drinks alcohol. These symptoms include flushing, coughing and labored breathing, nausea, apprehension, and sometimes vomiting. Disulfiram therapy rests on the theory that the medication helps to provide external controls on drinking until the individual can develop internal controls. The use of disulfiram appears to be most successful for those people who have decided to abstain from alcohol and who need an (often temporary) external aid in carrying out this decision.
Naltrexone (Narcan) is an opioid antagonist, that is, a drug that has the opposite pharmacologic effect of other drugs in its class. It prevents and reverses the pharmacologic activity of opioids. As this TIP was being prepared for publication, the U.S. Food and Drug Administration approved naltrexone for use in the treatment of alcohol addiction. Although this drug has been shown to reduce alcohol craving in some alcohol-dependent persons, more studies are needed before its full value as an adjunct to treatment is known.
Opioids administered during naltrexone therapy produce neither subjective effects such as euphoria nor pharmacologic effects such as analgesia. Naltrexone therapy rests on the theory that if the euphoric, rewarding effects of opioid use are blocked, there is less likelihood of repeated opioid use. Clients who are most likely to benefit from naltrexone therapy include people who have substantial social support for sobriety and who are well motivated for recovery.
Although the demand for AOD treatment is high, the majority of people requiring AOD treatment do not seek help. Those who do seek help often receive insufficient and inadequate treatment. This inadequacy may apply to people without health insurance or without AOD treatment coverage, gay men and lesbians, IDUs, HIV-infected AOD abusers, and people from cultural and ethnic minorities.
Inadequate treatment slots in the public sector. The demand for public AOD treatment is extremely great, especially among the two largest groups treated by public AOD treatment programs -- chronic AOD recidivists and the working poor. Chronic recidivists are people with severe addiction and prominent psychosocial dysfunction. They live from crisis to crisis, often with unmet basic needs. As chronic recidivists age, they exhaust AOD, mental health, and social service resources. Their crises become more severe and they require more from the AOD treatment program. Many are addicted to opioids and/or cocaine, and many engage in injecting drug use. As a group, they have a very high risk for HIV exposure as well as significant AOD treatment needs.
As a result of tremendous demand for public AOD treatment, many programs have long waiting lists. Thus, some people who need and want treatment may select a treatment modality that is inappropriate but available. In an effort to address problems related to AOD treatment availability, in 1993 the Federal Government published interim revised regulations that applied to States and AOD treatment programs receiving Federal substance abuse prevention and treatment block grant funds. The interim revised regulations, which are referred to throughout this TIP, are summarized in Appendix B.
Insufficient third-party coverage. Insurance companies and other third-party payers tightly control the type and intensity of AOD treatment coverage. Inpatient treatment is often limited to a few days of detoxification and management of psychiatric crises. Patients are rapidly moved to lower levels of intensity, based on coverage decisions by insurance and managed care company representatives.
AOD addiction is a chronic, progressive, biopsychosocial disease that is best treated by a biopsychosocial multidisciplinary treatment approach. Treatment can be provided by different types of providers (private sector and public sector); at different levels of care (inpatient, intensive outpatient, and outpatient); and through different program models (residential, day and evening treatment programs, and halfway homes). Treatment may include detoxification and maintenance on substitution therapy.
Substance abuse treatment has been shown to be an effective context in which to provide other treatment services to AOD abusers who might otherwise have no access to such services (O'Connor et al. 1992;Samet et al., 1992b;Umbricht-Schneiter et al., 1994). All types of AOD treatment involve contact with patients needing a variety of services related to HIV/AIDS, such as HIV testing, counseling, education, advocacy, case management, liaison with AIDS services and support groups, and medical care for HIV and related conditions.
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