Who Provides Treatment?
Many different kinds of professionals provide treatment for substance use disorders. In most treatment programs, the main caregivers are specially trained individuals certified or licensed as substance abuse treatment counselors. About half these counselors are people who are in recovery themselves. Many programs have staff from several different ethnic or cultural groups.
Most treatment programs assign patients to a treatment team of professionals. Depending on the type of treatment, teams can be made up of social workers, counselors, doctors, nurses, psychologists, psychiatrists or other professionals.
What Will Happen First?
Everyone entering treatment receives a clinical assessment. A complete assessment of an individual is needed to help treatment professionals offer the type of treatment that best suits him or her. The assessment also helps program counselors work with the person to design an effective treatment plan. Although clinical assessment continues throughout a person’s treatment, it starts at or just before a person’s admission to a treatment program. The counselor will begin by gathering information about the person, asking many questions such as those about:
- Kinds, amount and length of time of substance or alcohol use
- Cultural issues around use of alcohol or drugs
- Effects of drug or alcohol use on the person’s life
- Medical history
- Current medical problems or needs
- Current medications (including pain medication)
- Mental health issues or behavioral problems
- Family and social issues and needs
- Legal or financial problems
- Educational background and needs
- Current living situation and environment
- Employment history, stability, problems and needs
- School performance, problems and needs, if relevant
- Previous treatment experiences or attempts to quit drug or alcohol use
The counselor may invite you, as a family member, to answer questions and express your own concerns as well. Be honest — this is not the time to cover up your loved one’s behavior. The counselor needs to get a full picture of the problem to plan and help implement the most effective treatment. It is particularly important for the counselor to know whether your family member has any serious medical problems or whether you suspect that he or she may have an emotional problem. You may feel embarrassed answering some of these questions or have difficulty completing the interview, but remember: the counselor is there to help you and your loved one. The treatment team uses the information gathered to recommend the best type of treatment. No one type of treatment is right for everyone; to work, the treatment needs to meet your family member’s individual needs.
After the assessment, a counselor or case manager is assigned to your family member. The counselor works with the person (and possibly his or her family) to develop a treatment plan. This plan lists problems, treatment goals, and ways to meet those goals.
Based on the assessment, the counselor may refer your family member to a physician to decide whether he or she needs medical supervision to stop alcohol or drug use safely.
Medically Supervised Withdrawal
Medically supervised withdrawal (often called detoxification or detox) uses medication to help people withdraw from alcohol or drugs. People who have been taking large amounts of opioids (e.g., heroin, OxyContin® or codeine), barbiturates or sedatives (“downers”), pain medications, or alcohol — either alone or together — may need medically monitored or managed withdrawal services. Sometimes, alcohol withdrawal can be so severe that people hallucinate, have convulsions or develop other dangerous conditions. Medication can help prevent or treat such conditions. Anyone who has once had hallucinations or seizures from alcohol withdrawal or who has another serious illness or (in some cases) a mental disorder that could complicate detoxification may need medical supervision to detoxify safely. Medically supervised withdrawal can take place on a regular medical ward of a hospital, in a specialized inpatient detoxification unit, or on an outpatient basis with close medical supervision. Detoxification may take several days to a week or more. During that time, the person will receive medical care and may begin to receive education about his or her disease.
Not everyone needs inpatient medically supervised detox. People with mild withdrawal symptoms from alcohol or drugs and people using cocaine, marijuana, opioids or methamphetamine do not generally need to be hospitalized for detoxification. However, they may need outpatient medical care, a lot of support and someone to ensure their well-being.
Social detoxification can meet this need. Sometimes social detoxification centers are part of a residential treatment program; other times they are separate facilities. Social detoxification centers are not hospitals and seldom use medication, but the person does stay there from several days to one week. The social detoxification staff includes nurses and counselors. The staff watches each person’s medical condition closely, and counselors are available to help him or her through the most difficult part of withdrawing from alcohol and drugs.
It is important to know that detoxification is not treatment; it is a first step that can prepare a person for treatment.
My wife just started treatment. I called the program yesterday to ask the counselor some questions. The counselor said that she "could not confirm or deny" that my wife was even there! What’s that about?
Federal and state laws protect an individual’s privacy in treatment. Before the counselor can talk to anyone (including you) about your wife’s treatment, the program must first have her permission, in writing. Even if the counselor knows that you know your wife is there, she still can’t even say that your wife is in the program until your wife signs a "release of information" or "disclosure authorization" form. You may want to talk to your wife and be sure she understands that you would like to be involved in the treatment program.
What Types of Treatment Programs Are Available?
Several types of treatment programs are available:
- Inpatient treatment
- Residential programs
- Partial hospitalization or day treatment
- Outpatient and intensive outpatient programs
- Methadone clinics (also called opioid treatment programs)
Inpatient treatment, provided in special units of hospitals or medical clinics, offers both detoxification and rehabilitation services. Several years ago, many hospital-based treatment programs existed. Today, because of changes in insurance coverage, inpatient treatment is no longer as common as it used to be. People who have a mental disorder or serious medical problems as well as a substance use disorder are the ones most likely to receive inpatient treatment. Adolescents also may need the structure of inpatient treatment to make sure a full assessment of their substance use and mental disorders can be done.
Residential programs provide a living environment with treatment services. Several models of residential treatment (such as the therapeutic community) exist, and treatment in these programs lasts from a month to a year or more. The programs differ in some ways, but they are similar in many ways.
Residential programs often have phases of treatment, with different expectations and activities during each phase. For example, in the first phase, an adult’s contact with family, friends and job may be restricted. An adolescent may be able to have contact with his or her parents but not with friends or with school. This restriction helps the person become part of the treatment community and adjust to the treatment setting. In a later phase, a person may be able to start working again, going “home” to the facility every evening. If your loved one is in a residential treatment program, it is important that you know and understand the program rules and expectations. Often residential programs last long enough to offer general equivalency diploma (GED) preparation classes, training in job-seeking skills and even career training. In residential programs for adolescents, the participants attend school as a part of the program. Some residential programs are designed to enable women who need treatment to bring their children with them. These programs offer child care and parenting classes.
Residential programs are best for people who do not have stable living or employment situations and/or have limited or no family support. Residential treatment may help people with very serious substance use disorders who have been unable to get and stay sober or drug free in other treatment.
Partial Hospitalization or Day Treatment Programs
Partial hospitalization or day treatment programs also may be provided in hospitals or free-standing clinics. In these programs, the person attends treatment for four to eight hours per day but lives at home. These programs usually last for at least three months and work best for people who have a stable, supportive home environment.
Outpatient and Intensive Outpatient Programs
Outpatient and intensive outpatient programs provide treatment at a program site, but the person lives elsewhere (usually at home). Outpatient treatment is offered in a variety of places: health clinics, community mental health clinics, counselors’ offices, hospital clinics, local health department offices, or residential programs with outpatient clinics. Many meet in the evenings and on weekends so participants can go to school or work. Outpatient treatment programs have different requirements for attendance. Some programs require daily attendance; others meet only one to three times per week.
My brother is in a residential treatment program. He says he can leave the program at any time. Is this true?
Yes. Everyone has the option of leaving. All alcohol and drug abuse treatment is voluntary, although there may be consequences for leaving if the person is in treatment, for example, as part of probation or parole. If your brother chooses to leave and treatment has not been completed, the treatment staff may ask him to sign papers stating that he is leaving treatment against medical advice. The staff also will try to find out why he wants to leave early and will try to address any concerns he has.
Intensive outpatient treatment programs require a person to attend nine to 20 hours of treatment activities per week. Outpatient programs last from about two months to one year. People who do best in an outpatient program are willing to attend counseling sessions regularly, have supportive friends or family members, have a place to live, and have some form of transportation to get to treatment sessions (some programs will provide transportation if needed).
Opioid Treatment Programs
Opioid treatment programs (OTPs), sometimes known as methadone clinics, offer medication-assisted outpatient treatment for people who are dependent on opioid drugs (such as heroin, OxyContin® or vicodin). These programs use a medication, such as methadone or LAAM, to help a person not use illicit opioids. OTPs provide counseling and other services along with the medication.
What Actually Happens in Treatment Programs?
Although treatment programs differ, the basic ingredients of treatment are similar. Most programs include many or all elements presented below.
As we discussed earlier, all treatment programs begin with a clinical assessment of a person’s individual treatment needs. This assessment helps in the development of an effective treatment plan.
Programs in hospitals can provide this care on site. Other outpatient or residential programs may have doctors and nurses come to the program site for a few days each week, or a person may be referred to other places for medical care. Medical care typically includes screening and treatment for HIV/AIDS, hepatitis, tuberculosis and women’s health issues.
A Treatment Plan
The treatment team, along with the person in treatment, develops a treatment plan based on the assessment. A treatment plan is a written guide to treatment that includes the person’s goals, treatment activities designed to help him or her meet those goals, ways to tell whether a goal has been met, and a timeframe for meeting goals. The treatment plan helps both the person in treatment and treatment program staff stay focused and on track. The treatment plan is adjusted over time to meet changing needs and ensure that it stays relevant.
Group and Individual Counseling
At first, individual counseling generally focuses on motivating the person to stop using drugs or alcohol. Treatment then shifts to helping the person stay drug and alcohol free. The counselor attempts to help the person:
- See the problem and become motivated to change
- Change his or her behavior
- Repair damaged relationships with family and friends
- Build new friendships with people who don’t use alcohol or drugs
- Create a recovery lifestyle.
Group counseling is different in each program, but group members usually support and try to help one another cope with life without using drugs or alcohol. They share their experiences, talk about their feelings and problems, and find out that others have similar problems. Groups also may explore spirituality and its role in recovery.
People in treatment may be asked to read certain things (or listen to audiotapes), to complete written assignments (or record them on audiotapes) or to try new behaviors.
Education About Substance Use Disorders
People learn about the symptoms and the effects of alcohol and drug use on their brains and bodies. Education groups use videotapes or audiotapes, lectures or activities to help people learn about their illness and how to manage it.
Life Skills Training
This training can include learning and practicing employment skills, leisure activities, social skills, communication skills, anger management, stress management, goal setting, and money and time management.
Testing for Alcohol or Drug Use
Program staff members regularly take urine samples from people for drug testing. Some programs are starting to test saliva instead of urine. They also may use a Breathalyzer™ to test people for alcohol use.
Relapse Prevention Training
Relapse prevention training teaches people how to identify their relapse triggers, how to cope with cravings, how to develop plans for handling stressful situations, and what to do if they relapse. A trigger is anything that makes a person crave a drug. Triggers often are connected to the person’s past use, such as a person he or she used drugs with, a time or place, drug use paraphernalia (such as syringes, a pipe, or a bong), or a particular situation or emotion.
Orientation to Self-Help Groups
Participants in self-help groups support and encourage one another to become or stay drug and alcohol free. Twelve-step programs are perhaps the best known of the self-help groups. These programs include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous and Marijuana Anonymous. Other self-help groups include SMART (Self Management and Recovery Training) Recovery® and Women for Sobriety.
Members themselves, not treatment facilities, run self-help groups. In many places, self-help groups offer meetings for people with particular needs. You may find special meetings for young people; women; lesbian, gay and bisexual people; newcomers; and those who need meetings in languages other than English. Internet chat groups and online meetings also are available for some groups.
What are these "sober life skills" my partner talks about?
Sober life skills are the new behaviors and ways of living that your partner will need to work on. Before treatment, your partner spent a great deal of time obtaining a substance, using drugs or drinking alcohol, and getting over the substance’s effects. Most of his or her activities centered on drugs or alcohol. Most of his or her fun activities included drinking alcohol or using drugs, and many of your partner’s friends used or abused substances, too. For these reasons, people recovering from substance use disorders need to learn a whole new way to live and to make new friends.
Many treatment programs recommend or require attendance at self-help groups. By attending, many people make new friends who help them stay in recovery. The number of meetings required varies by treatment program; many programs require participants to attend "90 meetings in 90 days," as AA and NA recommend.
Some treatment programs encourage people to find a "sponsor," that is, someone who has been in the group for a while and can offer personal support and advice.
Self-help groups are very important in most people’s recovery. It is important to understand, however, that these groups are not the same as treatment. There are self-help groups for family members, too, such as Al-Anon and Alateen.
Treatment for Mental Disorders
Many people with a substance use disorder also have emotional problems such as depression, anxiety or posttraumatic stress disorder. Adolescents in treatment also may have behavior problems, conduct disorder or attention deficit/hyperactivity disorder.
Treating both the substance use and mental disorders increases the chances that the person will recover. Some counselors think people should be alcohol and drug free for at least three to four weeks before a treatment professional can identify emotional illness correctly. The program may provide mental health care, or it may refer a person to other sites for this care. Mental health care often includes the use of medications, such as antidepressants.
Family Education and Counseling Services
This education can help you understand the disease and its causes, effects and treatment. Programs provide this education in many ways: lectures, discussions, activities and group meetings. Some programs provide counseling for families or couples. Family counseling is especially critical in treatment for adolescents. Parents need to be involved in treatment planning and follow-up care decisions for the adolescent. Family members also need to participate as fully as possible in the family counseling the program offers.
Many programs use medications to help in the treatment process. Although no medications cure dependence on drugs or alcohol, some do help people stay abstinent and can be lifesaving.
Medication is the primary focus of some programs, such as the medication-assisted OTPs discussed earlier. Methadone is a medication that prevents opioid withdrawal symptoms for about 24 hours, so the person must take it daily. Taken as directed, it does not make a person high but allows him or her to function normally. In fact, methadone blocks the “high” a person gets from an opioid drug.
Some people stay on methadone for only six months to one year and then gradually stop taking it; most of these people relapse and begin to use opioids again. However, others stay on methadone for long periods of time or for life, which is called methadone maintenance treatment. People receiving this treatment often have good jobs and lead happy, productive lives.
If your family member is taking medications for HIV infection or AIDS or for any other medical condition, it is important that OTP staff members know exactly what he or she is taking. Mixing some medications with methadone or LAAM may mean that your family member will need special medical supervision.
Buprenorphine is another medication that may be used to treat opioid dependence and is sometimes used by OTPs. Buprenorphine recently was approved for treatment by primary care doctors in their offices. A doctor treating a patient with buprenorphine generally will provide or refer the patient for counseling, also.
Disulfiram (Antabuse®) is a medication that causes a bad reaction if people drink alcohol while taking it. The reaction is flushing, nausea, vomiting and anxiety. Because people know the medication will make them very ill if they drink alcohol, it helps them not to drink it. Antabuse is taken daily.
If substance use disorder is a disease, why aren’t there medicines that will help?
There are medicines that will help, although only for some addictions. No "magic pill" exists to cure substance use disorders, but medicines can often be an important part of the treatment. Medications are used to detoxify a person, to prevent him or her from feeling high from taking drugs, to reduce cravings, or to treat a person’s mental disorder.
Another medication, naltrexone (ReVia®), reduces the craving for alcohol. This medication can help keep people who drink a small amount of alcohol from drinking more of it. Programs also sometimes use naltrexone to treat heroin or other opioid dependence because it blocks the drug’s effects. It is important for people who use heroin to go through detox first, so they are heroin-free before starting to take naltrexone.
Because it is very difficult for a person to detoxify from opioid drugs, many people don’t make it that far; buprenorphine is sometimes used to help people make that transition. If a person does detoxify from opioids and begins to take naltrexone, it still will not work well for this purpose unless a person has a strong social support system, including someone who will make sure that he or she continues to take the medication regularly. When an adolescent is taking naltrexone to treat opioid dependence, it is particularly important that parents provide strong support and supervision.
Follow-Up Care (Also Called Continuing Care)
Even when a person has successfully completed a treatment program, the danger of returning to alcohol or drug use (called a “slip” or relapse) remains. The longer a person stays in treatment, including follow-up, the more likely he or she is to stay in recovery. Once a person has completed basic treatment, a program will offer a follow-up care program at the treatment facility or will refer him or her to another site. Most programs recommend that a person stay in follow-up care for at least one year. Adolescents often need follow-up care for a longer period.
Follow-up care is very important to successful treatment. Once a person is back in his or her community, back in school or back at work, he or she will experience many temptations and cravings for alcohol or drugs. In follow-up care, your family member will meet periodically with a counselor or a group to determine how he or she is coping and to help him or her deal with the challenges of recovery.
For some people, particularly those who have been in residential treatment or prison-based programs, more intensive forms of follow-up care may be helpful. Halfway houses or sober houses are alcohol- and drug-free places to live for people coming from a prison-based or residential program. People usually stay from three months to one year, and counseling is provided at the site or at an outpatient facility.
Supportive living or transitional apartments provide small group living arrangements for those who need a sober and drug-free living environment. The residents support one another, and involvement in outpatient counseling and self-help groups is expected.
Why Does Treatment Take So Long?
Substance use disorders affect every part of a person’s life. For that reason, treatment needs to affect every part of a person’s life as well.
Treatment involves more than helping someone stop drinking alcohol or using drugs. Actually, stopping alcohol use or drug use is just the beginning of the recovery process. Your family member will need to learn new ways to cope with daily life. He or she will need to relearn how to deal with stress, anger, or social situations and how to have fun without using drugs or drinking. Learning these new skills is a lot of work.
Many people enter treatment only because of pressure from the legal system, employers, parents, spouses or other family members. The first step in treatment then is to help them see that they do have a problem and to become motivated to change for themselves. This process often takes time.
Your family member also will need time to understand and begin to use the support of the self-help groups mentioned before. These groups will be important to his or her recovery for many years to come.
Remember: It can take a long time for the disease to develop and it is often chronic; therefore, it can take a long time to treat it.
Substance Abuse and Mental Health Services Administration
Substance Abuse Treatment Facility Locator
Source: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services