Questions to Ask Recovery Centers
- Does the program use treatments backed by scientific evidence?
Effective drug abuse treatments can include behavioral therapy, medications, or, ideally, their combination.
Behavioral therapies vary in focus and may involve:
• addressing a patient's motivation to change;
• providing incentives to stop taking drugs;
• building skills to resist drug use;
• replacing drug-using activities with constructive and rewarding activities;
• improving problem-solving skills; and
• building better personal relationships.
• Cognitive Behavioral Therapy. Seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.
• Motivational Incentives. Uses positive reinforcement such as providing rewards or privileges for remaining drug free, for participating in counseling sessions, or for taking treatment medications as prescribed.
• Motivational Interviewing. Uses strategies to encourage rapid and self-driven behavior change to stop drug use and help a patient enter treatment.
• Group Therapy. Helps patients face their drug abuse realistically, come to terms with its harmful consequences, and boost their motivation to stay drug free. Patients learn how to resolve their emotional and personal problems without abusing drugs.
Medications are an important part of treatment for many patients, especially when combined with counseling and other behavioral therapies. Different types of medications may be useful at different stages of treatment: to stop drug abuse, to stay in treatment, and to avoid relapse.
- Does the program tailor treatment to the needs of each patient?
No single treatment is right for everyone. The best treatment addresses a person's various needs, not just his or her drug abuse.
Matching treatment settings, programs, and services to a person's unique problems and level of need is key to his or her ultimate success in returning to a productive life. It is important for the treatment approach to be broad in scope, taking into account a person's age, gender, ethnicity, and culture. The severity of addiction and previous efforts to stop using drugs can also influence a treatment approach.
The best programs provide a combination of therapies and other services to meet a patient's needs. In addition to drug abuse treatment, a patient may require other medical services, family therapy, parenting support, job training, and social and legal services.
Finally, because addictive disorders and other mental disorders often occur together, a person with one of these conditions should be assessed for the other. And when these problems co-occur, treatment should address both (or all conditions), including use of medications, as appropriate.
Medications Available To Treat Drug Addiction
Currently, medications are available to treat opioid, tobacco, and alcohol addictions:
• Methadone, buprenorphine, and naltrexone are used to treat people addicted to opiates (e.g., heroin, prescription pain relievers);
• Nicotine patches, gum, lozenges, nasal spray, and the medications varenicline (Chantix) and bupropion (Wellbutrin) are used to treat tobacco addiction; and
• Disulfiram, acamprosate (Campral), naltrexone, and topiramate (Topamax) are used for treating alcohol dependence.
Medical detoxification is a necessary first step in the treatment of certain addictions, but by itself does little to change long-term drug use.
- Does the program adapt treatment as the patient's needs change?
Individual treatment and service plans must be assessed and modified as needed to meet changing needs.
A person in treatment may require varying combinations of services during its course, including ongoing assessment. For instance, the program should build in drug monitoring so the treatment plan can be adjusted if relapse occurs. For most people, a continuing care approach provides the best results, with treatment level adapted to a person's changing needs.
A patient's needs for support services, such as day care or transportation, should also be met during treatment.
- Is the duration of treatment sufficient?
Remaining in treatment for the right period of time is critical.
Appropriate time in treatment depends on the type and degree of a person's problems and needs. Research tells us that most addicted people need at least three months in treatment to really reduce or stop their drug use and that longer treatment times result in better outcomes. The best programs will measure progress and suggest plans for maintaining recovery. Recovery from drug addiction is a long-term process that often requires several episodes of treatment and ongoing support from family or community.
Relapse Does Not Mean Treatment Failure
The chronic nature of addiction means that relapsing to drug abuse is not only possible, but likely, similar to what happens with other chronic medical illnesses-such as diabetes, hypertension, and asthma-that have both physical and behavioral components. And like these illnesses, addiction also requires continual evaluation and treatment modification if necessary.
A relapse to drug use indicates a need to re-instate or adjust treatment strategy; it does not mean treatment has failed.
- How do 12-step or similar recovery programs fit into drug addiction treatment?
Self-help groups can complement and extend the effects of professional treatment.
The most well-known programs are Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. This group therapy model draws on the social support offered by peer discussion to help promote and sustain drug-free lifestyles.
Most drug addiction treatment programs encourage patients to participate in group therapy during and after formal treatment. These groups offer an added layer of community-level social support to help people in recovery with abstinence and other healthy lifestyle goals.
How Doctors Think: Addiction, Neuroscience and Your Treatment Plan
Lloyd I. Sederer, MD Medical editor, mental health for The Huffington Post
Ever wonder how a (good) doctor comes up with her/his recommendations for treatment? What the critical thinking underlying the suggestions might be? As an example, we can look at a comprehensive treatment plan for drug and alcohol addiction (forthcoming posts will look at other conditions, like depression, bipolar disorder and schizophrenia).
A premise I hold to is that comprehensive care should be a standard to aspire to as a patient, family member or clinician. Individual, proven treatments for a condition tend to augment one another (1+1 = >2) thereby providing a more robust response. An overreliance on one form of treatment (e.g., medications or therapy or 12-step alone), with the exception of other recognized approaches, often reflects a bias or limitation on the part of the clinician (or system of care) and seldom is in the ill person's interest.
A Substance Use Disorder (SUD) is defined as: the overuse or dependence on a drug with adverse effects on that person's physical and mental health, as well as negative consequences on others. The use of the substance, whether it is cocaine, Percodan, heroin, alcohol, marijuana or other drugs, persists despite clear and serious problems with family, work and personal relationships. Legal problems also tend to accrue.
Two related fields of science have substantially informed the treatment of a SUD -- which includes alcohol and legal and illicit drugs. These are the fields of biological and cognitive neuroscience. An understanding of the brain, still perhaps the most complex organ and system we know of, has grown vastly in recent decades. We understand far better the parts of the brain, their respective functions, their neurochemistry and circuitry, as well as how to impact them. We are far from claiming mastery of the central nervous system but that need not keep us from acting on what we know. Knowledge is what a good doctor brings to an encounter with a patient, and which should illuminate the opportunities for effective intervention.
As an example, let's consider those who are dependent upon heroin or narcotic analgesics (like Oxycontin, Percodan, and Methadone). An epidemic of their use has ravaged the U.S., accounting for more deaths than motor vehicle accidents and homicides. 12-step programs (AA, NA) have been the mainstay of intervention for SUD but today represent only one of a number of tools that can help. Comprehensive care calls for more than reliance on a 12-step program. That's where neuroscience comes in. Your doctor can offer more than AA or NA alone.
Instead of approaching addiction as a laundry list of signs and symptoms, aka conventional diagnosis, a doctor can now consider the underlying brain mechanisms driving the self-destructive behavior.
This link will take you to a psychiatric resident explaining how the brain works when addicted (it also mentions an anxiety disorder but that is extra). He uses the following drawing of the brain to describe how a treatment plan emerges from an understanding of the brain. The video is 15 minutes; the last six minutes focus on a treatment plan for a person with a narcotic addiction.
With permission from The National Neuroscience Curriculum Initiative (http://www.NNCIonline.org)
What this doctor understands -- how he thinks in developing recommendations for a patient -- is that the brain has a reward circuit that powerfully drives our behaviors. Of course, the brain is more complex but this is information for a patient and family, not a neuroscientist, and it is actionable.
Two sections of the brain (marked V & N above, the ventral tegmental area and the nucleus accumbens) signal a source of pleasure (instrumental to survival of the species - as are food and sex) by delivering a spike of dopamine. This is like an accelerator pedal. With addiction, that spike is from a narcotic not everyday life, hence the idea of how an addiction highjacks our brain from its normal sources of pleasure or reward.
The circuit then continues to the section marked O (orbital frontal cortex), which is instrumental to human drive and motivation. This region is then pumped up by the dopamine spike and gets us going, namely wanting more. It drives us to repeat the experience, even if it is a handful of narcotic pills or a needle in our arm. But it is the P (the prefrontal cortex), where judgment and reasoning reside, that can operate to control the drive, to put some brakes on the accelerator pedal now going at a very high RPM, so to speak.
Finally, there are the A/H (amygdala and hippocampus), which are regions of the brain that store the memory of what is so rewarding. They also register what is salient to the reward; these are the cues associated with the source. Remember, Pavlov's dogs salivated, over time, to the bell not to the food, which is known as a conditioned response. It is the reward that drives us to repeat the behavior -- to survive or simply to enjoy life. But the cues offer opportunities for intervention.
In a brain addicted to narcotics this circuit of five regions is pirated because opioids (heroin and synthetic narcotics like Oxycontin and other synthetic analgesics) directly boost dopamine in the V & N sections of the brain. This triggers the circuit to powerfully fire and drives a person to seek repetitive sources of the pleasure. However, that source is not love, or food, or altruism in this case, it is finding more narcotics to ingest.
Here is where the doctor can construct a comprehensive treatment plan that targets components of the circuit, and additively increases the patient's likelihood of success:
- A number of medications are now available (Medication Assisted Treatment of Addiction, or MAT) that either block the effect of the narcotic in the V & N regions (like naltrexone) or control its release to less intense levels (like buprenorphine -- or methadone). The doctor may suggest MAT as one part of the plan.
- Motivation to resist desire to re-experience the spike -- the O region -- can be enhanced by Motivational Interviewing (MI) a brief technique that has been used in addiction for many years, and is now popular in helping people with any number of problem behaviors (e.g., overeating, tobacco use and gambling).
- The section of our brain which labors to have us use good judgment, the P region, can be substantially helped by a variety of interventions, including NA/AA, family psychoeducation and support, and promoting coping skills (like surrounding yourself with people who are not addicts, eating and sleeping well, and stress reduction practices like yoga and slow breathing).
- Finally, the A/H regions can also be impacted, especially the H region. Environmental triggers can drive cravings and relapse; these include the sight of a needle or pill, contact with other addicts or dealers, commercials about pain relief, even reports of the OD death of Philip Seymour Hoffman. Cognitive Behavioral Treatment (CBT) can be very effective in enabling a person with a SUD to avoid or have a reduced response to a trigger.
A comprehensive plan for a person with a narcotic addiction would, therefore, (with the doctor employing Motivational Interviewing) offer the patient, and supportive loved ones, a plan that included MAT, 12-step recovery, family psychoeducation, CBT, and a number of wellness activities like yoga (and yogic breathing), meditation, exercise, nutritional food, as well as the company of those dedicated to life, not addiction. This is more than a menu of services, it is recommending effective action along a variety of critical brain and behavior pathways.
If I, or a loved one, had an addiction, I would want a doctor who thinks this way. A doctor who comprehends the complexity of addiction, its neuroscience underpinnings, and the variety of treatments and self-care that, when done together, can save a person, and their family, from the catastrophic effects of untreated addiction.
Is there an argument that can be made against comprehensive treatment of this sort? Not that I know of. But it does require an informed doctor who recognizes the power of attacking tough problems in a variety of ways that augment one another. It also requires a doctor who talks with, engages, her/his patient to help them help themselves. And, of course, it takes an informed patient, family, and public to expect no less.
Additional Treatment Resources