Primary care clinicians need to be familiar with available treatment resources for their patients who have diagnosed substance abuse or dependence disorders.

The clinician's responsibility to the patient does not end with the patient's entry into formal treatment; rather, the physician may become a collaborative part of the treatment team, or, minimally, continue to treat the patient's medical conditions during the specialized treatment, encourage continuing participation in the program, and schedule followup visits after treatment termination to monitor progress and help prevent relapse.

Understanding the specialized substance abuse treatment system, however, can be a challenging task. No single definition of treatment exists, and no standard terminology describes different dimensions and elements of treatment.

Describing a facility as providing inpatient care or ambulatory services characterizes only one aspect (albeit an important one): the setting.

Moreover, the specialized substance abuse treatment system differs around the country, with each State or city having its own peculiarities and specialties.

Minnesota, for example, is well known for its array of public and private alcoholism facilities, mostly modeled on the fixed-length inpatient rehabilitation programs initially established by the Hazelden Foundation and the Johnson Institute, which subscribe to a strong Alcoholics Anonymous (AA) orientation and have varying intensities of aftercare services.

California also offers a number of community-based social model public sector programs that emphasize a 12-Step, self-help approach as a foundation for life-long recovery.

In this chapter, the term treatment will be limited to describing the formal programs that serve patients with more serious alcohol and other drug problems who do not respond to brief interventions or other office-based management strategies.

It is also assumed that an in-depth assessment has been conducted to establish a diagnosis and to determine the most suitable resource for the individual's particular needs (see Chapter 4).

Directories of Local Substance Abuse Treatment Systems

The first step in understanding local resources is to collect information about the specialized drug and alcohol treatment currently available in the community.

In most communities, a public or private agency regularly compiles a directory of substance abuse treatment facilities that provides useful information about program services (e.g., type, location, hours, and accessibility to public transportation), eligibility criteria, cost, and staff complement and qualifications, including language proficiency.

This directory may be produced by the local health department, a council on alcoholism and drug abuse, a social services organization, or volunteers in recovery.

Additionally, every State has a single State-level alcohol and other drug authority that usually has the licensing and program review authority for all treatment programs in the State and often publishes a statewide directory of all alcohol and drug treatment programs licensed in the State.

Another resource is the National Council on Alcohol and Drug Dependence, which provides both assessment or referral for a sliding scale fee and distributes free information on treatment facilities nationally. Also, the Substance Abuse and Mental Health Services Administration distributes a National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs (1-800-729-6686).

Knowing the resources and a contact person within each will facilitate access to the system. One useful referral tool is a list of agencies organized across different characteristics, such as services tailored to meet the needs of special populations (e.g., women, adolescents, people who are HIV-positive, and minorities). Resources also should include self-help groups in the area.

Goals and Effectiveness of Treatment

While each individual in treatment will have specific long- and short-term goals, all specialized substance abuse treatment programs have three similar generalized goals (Schuckit, 1994;American Psychiatric Association, 1995):

Reducing substance abuse or achieving a substance-free life
Maximizing multiple aspects of life functioning
Preventing or reducing the frequency and severity of relapse

For most patients, the primary goal of treatment is attainment and maintenance of abstinence (with the exception of methadone-maintained patients), but this may take numerous attempts and failures at "controlled" use before sufficient motivation is mobilized.

Until the patient accepts that abstinence is necessary, the treatment program usually tries to minimize the effects of continuing use and abuse through education, counseling, and self-help groups that stress reducing risky behavior, building new relationships with drug-free friends, changing recreational activities and lifestyle patterns, substituting substances used with less risky ones, and reducing the amount and frequency of consumption, with a goal of convincing the patient of her individual responsibility for becoming abstinent (American Psychiatric Association, 1995).

Total abstinence is strongly associated with a positive long-term prognosis.

Becoming alcohol- or drug-free, however, is only a beginning. Most patients in substance abuse treatment have multiple and complex problems in many aspects of living, including medical and mental illnesses, disrupted relationships, underdeveloped or deteriorated social and vocational skills, impaired performance at work or in school, and legal or financial troubles.

These conditions may have contributed to the initial development of a substance use problem or resulted from the disorder. Substantial efforts must be made by treatment programs to assist patients in ameliorating these problems so that they can assume appropriate and responsible roles in society.

This entails maximizing physical health, treating independent psychiatric disorders, improving psychological functioning, addressing marital or other family and relationship issues, resolving financial and legal problems, and improving or developing necessary educational and vocational skills.

Many programs also help participants explore spiritual issues and find appropriate recreational activities.

Increasingly, treatment programs are also preparing patients for the possibility of relapse and helping them understand and avoid dangerous "triggers" of resumed drinking or drug use. Patients are taught how to recognize cues, how to handle craving, how to develop contingency plans for handling stressful situations, and what to do if there is a "slip."

Relapse prevention is particularly important as a treatment goal in an era of shortened formal, intensive intervention and more emphasis on aftercare following discharge.

While the effectiveness of treatment for specific individuals is not always predictable, and different programs and approaches have variable rates of success, evaluations of substance abuse treatment efforts are encouraging.

All the long-term studies find that "treatment works" -- the majority of substance-dependent patients eventually stop compulsive use and have less frequent and severe relapse episodes (American Psychiatric Association, 1995;Landry, 1996).

The most positive effects generally happen while the patient is actively participating in treatment, but prolonged abstinence following treatment is a good predictor of continuing success. Almost 90 percent of those who remain abstinent for 2 years are also drug- and alcohol-free at 10 years (American Psychiatric Association, 1995).

Patients who remain in treatment for longer periods of time are also likely to achieve maximum benefits -- duration of the treatment episode for 3 months or longer is often a predictor of a successful outcome (Gerstein and Harwood, 1990).

Furthermore, individuals who have lower levels of premorbid psychopathology and other serious social, vocational, and legal problems are most likely to benefit from treatment.

Continuing participation in aftercare or self-help groups following treatment also appears to be associated with success (American Psychiatric Association, 1995).

An increasing number of randomized clinical trials and other outcome studies have been undertaken in recent years to examine the effectiveness of alcohol and various forms of drug abuse treatment. It is beyond the scope of this chapter to report the conclusions in any depth. However, a few summary statements from an Institute of Medicine report on alcohol studies are relevant:

No single treatment approach is effective for all persons with alcohol problems, and there is no overall advantage for residential or inpatient treatment over outpatient care.

Treatment of other life problems associated with drinking improves outcomes.

Therapist and patient (and problem) characteristics, treatment process, posttreatment adjustment factors, and the interactions among these variables also determine outcomes.

Patients who significantly reduce alcohol consumption or become totally abstinent usually improve their functioning in other areas (Institute of Medicine, 1990).

A recent comparison of treatment compliance and relapse rates for patients in treatment for opiate, cocaine, and nicotine dependence with outcomes for three common and chronic medical conditions (i.e., hypertension, asthma, and diabetes) found similar response rates across the addictive and chronic medical disorders (National Institute on Drug Abuse, 1996).

All of these conditions require behavioral change and medication compliance for successful treatment. The conclusion is that treatment of drug addiction has a similar success rate as treatment of other chronic medical conditions (National Institute on Drug Abuse, 1996).

Treatment Dimensions

The terminology describing the different elements of treatment care for people with substance use disorders has evolved as specialized systems have developed and as treatment has adapted to changes in the health care system and financing arrangements.

Important differences in language persist between public and private sector programs and, to a lesser extent, in treatment efforts originally developed and targeted to persons with alcohol- as opposed to illicit drug-related problems.

Programs are increasingly trying to meet individual needs and to tailor the program to the patients rather than having a single standard format with a fixed length of stay or sequence of specified services.

A recent publication of the Substance Abuse and Mental Health Services Administration, Overview of Addiction Treatment Effectiveness(Landry, 1996), divides substance abuse treatment along three dimensions: (1) treatment approach -- the underlying philosophical principles that guide the type of care offered and that influence admission and discharge policies as well as expected outcomes, attitudes toward patient behavior, and the types of personnel who deliver services; (2) treatment setting -- the physical environment in which care is delivered; and (3) treatment components -- the specific clinical interventions and services offered to meet individual needs.

These services can be offered for varying lengths of time and delivered at differing intensities. Another important dimension is treatment stage, because different resources may be targeted at different phases along a continuum of recovery. Programs also have been developed to serve special populations -- by age, gender, racial and ethnic orientation, drug of choice, and functional level or medical condition. Some of these offer the most appropriate environment and services for special populations.

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From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians