Drug rehabilitation

Drug rehabilitation (often drug rehab or just rehab) measuring the treatment providers responses on the Spir-
is a term for the processes of medical or psychotherapeu- itual Belief Scale (a scale measuring belief in the four
tic treatment, for dependency on psychoactive substances spiritual characteristics AA identied by Ernest Kurtz);
such as alcohol, prescription drugs, and street drugs such the scores were found to explain 41% of the variance in
as cocaine, heroin or amphetamines. The general intent the treatment providers responses on the Addiction Be-
is to enable the patient to confront substance dependence, lief Scale (a scale measuring adherence to the disease
if present, and cease substance abuse in order to avoid the model or the free-will model addiction).[3]
psychological, legal, nancial, social, and physical conse- Scientic research since 1970 shows that eective treat-
quences that can be caused, especially by extreme abuse. ment addresses the multiple needs of the patient rather
Treatment includes medication for depression or other than treating addiction alone. In addition, medically as-
disorders, counseling by experts and sharing of experi- sisted drug detoxication or alcohol detoxication alone
ence with other addicts. Some rehab centers include med- is ineective as a treatment for addiction. The National
itation and spiritual wisdom in the treatment process. A Institute on Drug Abuse (NIDA) recommends detoxica-
few centers also treat gambling with the same techniques tion followed by both medication (where applicable) and
as are used in drug rehabilitation.[1] behavioral therapy, followed by relapse prevention. Ac-
cording to NIDA, eective treatment must address med-
ical and mental health services as well as follow-up op-
1 Psychological dependency tions, such as community or family based recovery sup-
port systems.[4] Whatever the methodology, patient mo-
Psychological dependency is addressed in many drug re- tivation is an important factor in treatment success.
habilitation programs by attempting to teach the patient For individuals addicted to prescription drugs, treat-
new methods of interacting in a drug-free environment. ments tend to be similar to those who are addicted to
In particular, patients are generally encouraged, or possi- drugs aecting the same brain systems. Medication like
bly even required, to not associate with friends who still methadone and buprenorphine can be used to treat ad-
use the addictive substance. Twelve-step programs en- diction to prescription opiates, and behavioral therapies
courage addicts not only to stop using alcohol or other can be used to treat addiction to prescription stimulants,
drugs, but to examine and change habits related to their benzodiazepines, and other drugs.[5]
addictions. Many programs emphasize that recovery is a
permanent process without culmination. For legal drugs Types of behavioral therapy include:
such as alcohol, complete abstentionrather than at-
tempts at moderation, which may lead to relapseis also Cognitive-behavioral therapy, which seeks to help
emphasized (One is too many, and a thousand is never patients to recognize, avoid and cope with situations
enough.) Whether moderation is achievable by those in which they are most likely to relapse.
with a history of abuse remains a controversial point, but
is generally considered unsustainable. [2] Multidimensional family therapy, which is designed
to support recovery of the patient by improving fam-
ily functioning.
2 Types of treatment Motivational interviewing, which is designed to in-
crease patient motivation to change behavior and en-
Various types of programs oer help in drug rehabili- ter treatment.[6]
tation, including: residential treatment (in-patient), out-
Motivational incentives, which uses positive rein-
patient, local support groups, extended care centers, re-
forcement to encourage abstinence from the addic-
covery or sober houses, addiction counselling, mental
tive substance.[7]
health, and medical care. Some rehab centers oer age-
and gender-specic programs.
In a survey of treatment providers from three separate 2.1 Medications
institutions (the National Association of Alcoholism and
Drug Abuse Counselors, Rational Recovery Systems and Certain opioid medications such as methadone and more
the Society of Psychologists in Addictive Behaviors) recently buprenorphine (In America, "Subutex" and

1
2 4 COUNSELING

"Suboxone") are widely used to treat addiction and de- high risk situations.[11]
pendence on other opioids such as heroin, morphine or Nitrous oxide has been shown to be an eective treatment
oxycodone. Methadone and buprenorphine are main- for a number of addictions.[12][13][14]
tenance therapies intended to reduce cravings for opi-
ates, thereby reducing illegal drug use, and the risks as-
sociated with it, such as disease, arrest, incarceration, 2.2 Residential treatment
and death, in line with the philosophy of harm reduc-
tion. Both drugs may be used as maintenance medica- In-patient residential treatment for alcohol abuse is ex-
tions (taken for an indenite period of time), or used pensive and common in the U.S. Most American pro-
as detoxication aids.[8] All available studies collected grams follow a traditional 28-day program length. The
in the 2005 Australian National Evaluation of Pharma- length is based solely upon providers experience in the
cotherapies for Opioid Dependence suggest that mainte- 1940s that clients needed about one week to get over the
nance treatment is preferable,[8] with very high rates (79 physical changes, another week to understand the pro-
100%)[8] of relapse within three months of detoxication gram, and another week or two to become stable.[15] Sev-
from LAAM, buprenorphine, and methadone.[8][9] enty to 80 percent of American residential alcohol treat-
Ibogaine is a hallucinogenic drug promoted by certain ment programs provide 12-step therapy.[15]
fringe groups to interrupt both physical dependence and
psychological craving to a broad range or drugs including
narcotics, stimulants, alcohol and nicotine. To date, there 2.3 Experimental treatment
have never been any controlled studies showing it to be ef-
fective, and it is accepted as a treatment by no association The Nature of Things, a CBC Television program by
of physicians, pharmacists, or addictionologists. There David Suzuki, explored an experimental drug treatment
have been several deaths related to ibogaine use, which by Dr. Gabor Mat who works with addicts in Vancouver
causes tachycardia and long QT syndrome. The drug is which uses the substance Ayahuasca.[16]
an illegal Schedule I controlled substance in the United
States, and the foreign facilities in which it is adminis-
tered tend to have little oversight, and range from motel 3 Criminal justice
rooms to one moderately-sized rehabilitation center.[10]
Some antidepressants also show usefulness in moderat-
ing drug use, particularly to nicotine, and it has become Drug rehabilitation is sometimes part of the criminal jus-
common for researchers to re-examine already approved tice system. People convicted of minor drug oenses
drugs for new uses in drug rehabilitation. may be sentenced to rehabilitation instead of prison, and
those convicted of driving while intoxicated are some-
According to the National Institute on Drug Abuse times required to attend Alcoholics Anonymous meet-
(NIDA), patients stabilized on adequate, sustained doses ings. There are a number of ways to address an alternative
of methadone or buprenorphine can keep their jobs, avoid sentence in a drug possession or DUI case; increasingly,
crime and violence, and reduce their exposure to HIV and American courts are willing to explore outside-the-box
Hepatitis C by stopping or reducing injection drug use methods for delivering this service. There have been law-
and drug-related high risk sexual behavior. Naltrexone suits led, and won, regarding the requirement of attend-
is a long-acting opioid antagonist with few side eects. ing Alcoholics Anonymous and other twelve-step meet-
It is usually prescribed in outpatient medical conditions. ings as being inconsistent with the Establishment Clause
Naltrexone blocks the euphoric eects of alcohol and of the First Amendment of the U. S. Constitution, man-
opiates. Naltrexone cuts relapse risk during the rst 3 dating separation of church and state.[17][18]
months by about 36%.[8] However, it is far less eec-
tive in helping patients maintain abstinence or retaining In some cases, individuals can be court ordered to drug
them in the drug-treatment system (retention rates av- rehabilitation by the state through legislation like the
erage 12% at 90 days for naltrexone, average 57% at Marchman Act.
90 days for buprenorphine, average 61% at 90 days for
methadone).[8]
Acamprosate, disulram and topiramate (a novel
4 Counseling
anticonvulsant sulphonated sugar) are also used to treat
alcohol addiction. Acamprosate has shown eectiveness Traditional addiction treatment is based primarily on
for patients with severe dependence, helping them to counseling.
maintain abstinence for several weeks or months. Disul- Counselors help individuals identifying behaviors and
ram (also called Antabuse) produces a very unpleasant problems related to their addiction. It can be done on
reaction when drinking alcohol that includes ushing, an individual basis, but its more common to nd it in a
nausea and palpitations. It is more eective for patients group setting and can include crisis counseling, weekly or
with high motivation and some addicts use it only for daily counseling, and drop-in counseling supports. They
4.2 Client-centered approaches
are trained to develop recovery programs that help to
reestablish healthy behaviors and provide coping strate-
gies whenever a situation of risk happens. Its very com-
mon to see them work also with family members who
are aected by the addictions of the individual, or in a
community in order to prevent addiction and educate the
public. Counselors should be able to recognize how ad-
diction aects the whole person and those around him
or her.[19] Counseling is also related to Intervention"; a
process in which the addicts family requests help from
a professional in order to get this person into drug treat-
ment. This process begins with one of this professionals
rst goals: breaking down denial of the person with the
addiction. Denial implies lack of willingness from the pa-
tients or fear to confront the true nature of the addiction
and to take any action to improve their lives, besides of
continuing the destructive behavior. Once this has been
achieved, professional coordinates with the addicts fam-
ily to support them on getting this family member to al-
cohol drug rehabilitation immediately, with concern and
care for this person. Otherwise, this person will be asked
to leave and expect no support of any kind until going into
drug rehabilitation or alcoholism treatment. An interven-
tion can also be conducted in the workplace environment
with colleagues instead of family.
One approach with limited applicability is the Sober
Coach. In this approach, the client is serviced by
provider(s) in his or her home and workplace for any
ecacy, around-the-clock who functions much like a
nanny to guide or control the patients behavior.
4.1 Twelve-step programs
The disease model of addiction has long contended the
maladaptive patterns of alcohol and substance use dis-
played by addicted individuals are the result of a life-
long disease that is biological in origin and exacerbated
by environmental contingencies. This conceptualization
renders the individual essentially powerless over his or
her problematic behaviors and unable to remain sober by
himself or herself, much as individuals with a terminal
illness are unable to ght the disease by themselves with-
out medication. Behavioral treatment, therefore, neces-
sarily requires individuals to admit their addiction, re-
nounce their former lifestyle, and seek a supportive so-
cial network who can help them remain sober. Such ap-
proaches are the quintessential features of Twelve-step
programs, originally published in the book Alcoholics
Anonymous in 1939.[20] These approaches have met con-
siderable amounts of criticism, coming from opponents
who disapprove of the spiritual-religious orientation on
both psychological[21] and legal[22] grounds. Nonetheless,
despite this criticism, outcome studies have revealed that
aliation with twelve-step programs predicts abstinence
success at 1-year follow-up for alcoholism. Dierent re-
sults have been reached for other drugs, with the twelve
steps being less benecial for addicts to illicit substances,
3
and least benecial to those addicted to the physiolog-
ically and psychologically addicting opioids, for which
maintenance therapies are the gold standard of care.[23]
4.2 Client-centered approaches
In his inuential book, Client-Centered Therapy, in which
he presented the client-centered approach to therapeu-
tic change, psychologist Carl Rogers proposed there are
three necessary and sucient conditions for personal
change: unconditional positive regard, accurate empa-
thy, and genuineness. Rogers believed the presence of
these three items in the therapeutic relationship could
help an individual overcome any troublesome issue, in-
cluding alcohol abuse. To this end, a 1957 study[24] com-
pared the relative eectiveness of three dierent psy-
chotherapies in treating alcoholics who had been commit-
ted to a state hospital for sixty days: a therapy based on
two-factor learning theory, client-centered therapy, and
psychoanalytic therapy. Though the authors expected
the two-factor theory to be the most eective, it actu-
ally proved to be deleterious in outcome. Surprisingly,
client-centered therapy proved most eective. It has been
argued, however, these ndings may be attributable to
the profound dierence in therapist outlook between the
two-factor and client-centered approaches, rather than to
client-centered techniques per se.[25] The authors note
two-factor theory involves stark disapproval of the clients
irrational behavior (p. 350); this notably negative out-
look could explain the results.
A variation of Rogers approach has been developed in
which clients are directly responsible for determining the
goals and objectives of the treatment. Known as Client-
Directed Outcome-Informed therapy (CDOI), this ap-
proach has been utilized by several drug treatment pro-
grams, such as Arizonas Department of Health Ser-
vices.[26]
4.3 Psychoanalysis
Psychoanalysis, a psychotherapeutic approach to behav-
ior change developed by Sigmund Freud and modied by
his followers, has also oered an explanation of substance
abuse. This orientation suggests the main cause of the
addiction syndrome is the unconscious need to entertain
and to enact various kinds of homosexual and perverse
fantasies, and at the same time to avoid taking respon-
sibility for this. It is hypothesised specic drugs facil-
itate specic fantasies and using drugs is considered to
be a displacement from, and a concomitant of, the com-
pulsion to masturbate while entertaining homosexual and
perverse fantasies. The addiction syndrome is also hy-
pothesised to be associated with life trajectories that have
occurred within the context of traumatogenic processes,
the phases of which include social, cultural and political
factors, encapsulation, traumatophilia, and masturbation
4 5
as a form of self-soothing.[27] Such an approach lies in
stark contrast to the approaches of social cognitive the-
ory to addictionand indeed, to behavior in general
which holds human beings regulate and control their own
environmental and cognitive environments, and are not
merely driven by internal, driving impulses. Addition-
ally, homosexual content is not implicated as a necessary
feature in addiction.
4.3.1 Relapse prevention
An inuential cognitive-behavioral approach to addiction
recovery and therapy has been Alan Marlatts (1985) Re-
lapse Prevention approach.[28] Marlatt describes four psy-
chosocial processes relevant to the addiction and relapse
processes: self-ecacy, outcome expectancies, attribu-
tions of causality, and decision-making processes. Self-
ecacy refers to ones ability to deal competently and
eectively with high-risk, relapse-provoking situations.
Outcome expectancies refer to an individuals expecta-
tions about the psychoactive eects of an addictive sub-
stance. Attributions of causality refer to an individuals
pattern of beliefs that relapse to drug use is a result of
internal, or rather external, transient causes (e.g., allow-
ing oneself to make exceptions when faced with what are
judged to be unusual circumstances). Finally, decision-
making processes are implicated in the relapse process
as well. Substance use is the result of multiple decisions
whose collective eects result in consumption of the in-
toxicant. Furthermore, Marlatt stresses some decisions
referred to as apparently irrelevant decisionsmay seem
inconsequential to relapse, but may actually have down-
stream implications that place the user in a high-risk sit-
uation.
For example: As a result of heavy trac, a recovering
alcoholic may decide one afternoon to exit the highway
and travel on side roads. This will result in the creation of
a high-risk situation when he realizes he is inadvertently
driving by his old favorite bar. If this individual is able
to employ successful coping strategies, such as distract-
ing himself from his cravings by turning on his favorite
music, then he will avoid the relapse risk (PATH 1) and
heighten his ecacy for future abstinence. If, however,
he lacks coping mechanismsfor instance, he may be-
gin ruminating on his cravings (PATH 2)then his ef-
cacy for abstinence will decrease, his expectations of
positive outcomes will increase, and he may experience
a lapsean isolated return to substance intoxication. So
doing results in what Marlatt refers to as the Abstinence
Violation Eect, characterized by guilt for having got-
ten intoxicated and low ecacy for future abstinence in
similar tempting situations. This is a dangerous pathway,
Marlatt proposes, to full-blown relapse.
BEHAVIORAL MODELS
4.3.2 Cognitive therapy
An additional cognitively-based model of substance
abuse recovery has been oered by Aaron Beck, the fa-
ther of cognitive therapy and championed in his 1993
book, Cognitive Therapy of Substance Abuse.[29] This
therapy rests upon the assumption addicted individuals
possess core beliefs, often not accessible to immedi-
ate consciousness (unless the patient is also depressed).
These core beliefs, such as I am undesirable, acti-
vate a system of addictive beliefs that result in imagined
anticipatory benets of substance use and, consequen-
tially, craving. Once craving has been activated, per-
missive beliefs (I can handle getting high just this one
more time) are facilitated. Once a permissive set of
beliefs have been activated, then the individual will ac-
tivate drug-seeking and drug-ingesting behaviors. The
cognitive therapists job is to uncover this underlying sys-
tem of beliefs, analyze it with the patient, and thereby
demonstrate its dysfunctionality. As with any cognitive-
behavioral therapy, homework assignments and behav-
ioral exercises serve to solidify what is learned and dis-
cussed during treatment.[30]
4.4 Emotion regulation and mindfulness
A growing literature is demonstrating the importance of
emotion regulation in the treatment of substance abuse.
Considering that nicotine and other psychoactive sub-
stances such as cocaine activate similar psychopharma-
cological pathways,[31] an emotion regulation approach
may be applicable to a wide array of substance abuse.
Proposed models of aect-driven tobacco use have fo-
cused on negative reinforcement as the primary driving
force for addiction; according to such theories, tobacco is
used because it helps one escape from the undesirable ef-
fects of nicotine withdrawal or other negative moods.[32]
Acceptance and commitment therapy (ACT), is show-
ing evidence that it is eective in treating substance
abuse, including the treatment of poly-substance abuse
and cigarette smoking.[33][34] Mindfulness programs that
encourage patients to be aware of their own experi-
ences in the present moment and of emotions that arise
from thoughts, appear to prevent impulsive/compulsive
responses.[32][35] Research also indicates that mindfulness
programs can reduce the consumption of substances such
as alcohol, cocaine, amphetamines, marijuana, cigarettes
and opiates.[35][36][37]
5 Behavioral models
Main article: Community Reinforcement Approach and
Family Training
Behavioral models make use of principles of functional
analysis of drinking behavior. Behavior models exists for

both working with the substance abuser (Community Re-
inforcement Approach) and their family (Community Re-
inforcement Approach and Family Training). Both these
models have had considerable research success for both
ecacy and eectiveness. This model lays much empha-
sis on the use of problem solving techniques as a means
of helping the addict to overcome his addiction.
6 See also
Coerced abstinence
Drug policy of the Soviet Union
Dual diagnosis
Self-medication
Sober living environment
Sober Coach
Procovery
7 References
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 7

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