WHAT’S NEW IN ADDICTION TREATMENT?
Appeared in The
Ken Bachrach, Ph.D.
There
have been many changes in the field of addiction in the past fifteen
years. First, drugs of abuse have
changed considerably. Methamphetamine
is now the number one abused hard drug in the world, with there being more methamphetamine
addicts than heroin and cocaine addicts combined. World-wide there are over 26 million
methamphetamine users, with 1.4 million of them being in the
Much
has changed in terms of our understanding of addiction and the brain. We are now able to use brain scans to see
which parts of the brain light up when we use drugs or think about using
them. We can identify the parts of the
brain associated with craving states, which is the precursor to relapse. Medications are being developed to damper
these craving states so that the frontal lobes can take over and make more
appropriate decisions for the individual.
Still, these cravings can be very powerful, since they often resemble
other built-in motivational systems we need for survival. In fact, the brain may be tricked into thinking
we need drugs to survive, which may explain the driven state often associated with
individuals addicted to substances. In
addition, there is classical conditioning going on at the same time, which
further drives the person to want to use and act on these impulses.
The
field of addiction has entered its adolescent and is slowly maturing. There is now a consensus of treatment
principles that were developed by clinicians and researchers working together. There is an emphasis on disseminating
evidenced- based treatment approaches to providers, although there still is
difficulty in getting providers trained to use this information. One area that seems to have been successfully
disseminated is the recognition that confrontational approaches to engage individuals
is often counterproductive, and the recognition that most people entering
treatment for an addictive disorder are ambivalent at best. Engagement is now viewed as a separate and
distinct part of the treatment process, and the failure to recognize this can
lead to much lower retention rates.
Motivational counseling approaches are now used regularly by treatment
providers, and this is one area where mental health professionals, who
generally don’t work in the addiction field, can learn a thing or two. This requires assessing the state of change a person is in when they
first seek treatment, since different clinical tools and skills should be used,
depending on their stage of change.
Once
you’ve identified that a person has an addictive disorder, how do you determine
the level of care they need? Over the
past ten years, a patient placement criteria,
developed by the American Society of Addiction Medicine, has become the
national standard for determining patient placement for individuals with
addictive and co-occurring psychological disorders. Most states and managed care companies use
some form of this criteria, and it provides a very useful framework to both
conceptualize cases and communicate one’s findings to others. There are six dimensions, with three being
the usual medical necessity ones and three being more psychosocial in
nature. Two individuals can be using the
same amount of substances, but based on the application of these criteria may
be appropriately placed at different levels of care.
A
major paradigm shift occurring in the addiction field is the viewing of
addiction as a chronic disease. A
ground-breaking article was published in 2000 in the Journal of the American Medical Association by the well-respected
researcher, Tom McLellan and colleagues, which compared compliance and relapse
rates for addictive disorders to those for insulin dependent diabetes,
medication dependent hypertension, and asthma.
Surprisingly, relapse rates for addictive disorders looked very similar
to those other chronic diseases. Yet the
model of care for other chronic diseases is quite different than that provided
for addictive disorders. Imagine telling
a diabetic that it’s their third visit to the emergency room this year, and
since they don’t seem to be able to manage their weight and diet, we will no
longer provide care to them! Yet for
substance abuse this is unfortunately how we often establish benefit plans and
treatment, with lifetime limits to care, even though the total economic costs
to society for addictive disorders is greater than that for cancer and heart
disease. Studies of individuals with
serious and persistent addictive disorders reveal that these individuals have a
death rate 50 to 100 times the rate of the general population in the same age
range, and that those who achieve one year of stable recovery, do so following
three to four treatment episodes over a span of eight years. The outlook is not so dismal for all
individuals, just like it is not for all people with mental disorders. Still, there is a need to examine how we
provide care to people with addictive disorders and reframe addiction as a
health problem.
Ken Bachrach, Ph.D. is Clinical Director of Tarzana Treatment
Centers. He has been engaged in clinical
practice, research, and training in the field of substance abuse and
co-occurring disorders for over 20 years.
Dr. Bachrach is site Principal Investigator in NIDA’s Clinical Trials
Network, which tests new and promising treatment protocols. Also, he is President of Professional Psych
Seminars, a leading continuing education provider for psychologists and other
mental health professionals.