How do rehabilitation programs for addiction work?

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Treatment for substance use disorder first involves an evaluation of the nature of the drug or drugs used. Also essential is knowing the extent of addiction because early identification usually lessens the difficulty of overcoming the physiological and psychological effects of drug abuse. Equally important is determining the degree to which the person is committed to his or her rehabilitation. Thus, rehabilitation programs should attempt to adjust their mission and goals, as well as their therapeutic methods, to meet a wide range of patient needs and capacities.
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Since the mid-twentieth century, enormous amounts of money have been spent by individuals, families, governments, and private foundations to establish short- to long-term rehabilitation programs for those suffering from the disease of addiction and as well as substance abusers. Proponents of reducing the problems of drug addiction and substance abuse have long debated just how to accomplish this goal.

Some have favored strict enforcement of drug and drug-trade laws (thus identifying with the criminal justice system). Statistics suggest that this path demands higher levels of public funding than do programs aimed at the prevention of addiction and the rehabilitation of addicts. Opponents believe that the Reagan-era "War on Drugs" has long since failed and that addiction treatment needs to be taken out of the court system and housed solely under a medical and psychiatric umbrella. Supporters of early prevention of drug addiction emphasize the importance of educational programs, both in local communities and at all levels of the public education system. Thus, rehabilitation programs have never been excluded from the debate but have been ranked variously in public opinion and among possible funding agencies, both public and private.

One of the earliest and most widely used methods for treating drug addiction (treatment that has gradually been replaced by more personal therapeutic approaches) involves the use of the drug methadone. Methadone (not to be confused with the highly addictive drug meth, or methamphetamine) is a synthetic opioid that, like several highly addictive drugs, interacts with brains opioid receptors located mainly in the central and peripheral nervous system. Opium, as its name suggests, is the best-known drug containing natural opiates (alkaloids contained in the resin of the opium poppy), but other drugs, including heroin and morphine, have similar effects on the nervous system. The physiological effects of other well-known drugs including cocaine, crack cocaine, and methamphetamine are different, so individuals who are dependent on these narcotics do not respond to rehabilitation methods involving opioid substitutes like methadone and thus must be treated with a different methodology.

Beginning in the late 1930s (when it was first produced by German chemists) methadone was used by European doctors as an analgesic, or painkiller. After its introduction in the United States in 1947, physicians and hospitals working with patients who were addicted to opium, heroin, or morphine pioneered its use to counter or to replace the euphoric effects experienced by opioid-dependent patients. This method of rehabilitation came to be known as methadone maintenance treatment, or MMT.

By administering controlled doses of methadone, usually through the agency of outpatient methadone clinics, physicians can essentially control patients’ cravings for addictive drugs and do so while avoiding the most dangerous chemical effects of true narcotic drugs. In later years a number of different products have joined and sometimes replaced methadone in cases where drugs are used in rehabilitation programs. One of these drugs, buprenorphine (sold by pharmacists as Subutex or Suboxone), is a high-strength compound extracted from thebaine, an alkaloid in opium poppies.

Whatever the specific addictive drug may be (and whatever therapeutic procedure is followed), chances for full rehabilitation are usually higher when the problem of addiction is identified in its early stages. This scenario is more likely to occur when the affected person becomes aware of the need to stop a drug habit before it becomes serious. Rehabilitation therapists also emphasize the importance of the family as a first-stage support group in such cases. Contrary conditions are often (but not always) associated with addicted persons who are somehow forced into a detoxification (or detox) program because they have reached physically dangerous levels of addiction, have exhibited recurring suicidal tendencies, or have been ordered to begin rehabilitation following arrest and prosecution by court authorities.

Among the first steps taken in the rehabilitation process is the attempt to evaluate the actual degree of motivation impelling addicts to seek help. If the process is essentially ordered by a court, many believe that levels of motivation tend to be lower. Studies have shown, however, that when individuals suffering from substance use disorders have a period of time away from the drugs they are addicted to, the brain is allowed to clear and begin to heal, which in turn prompts the individual to be motivated to continue with rehabilitative care.

Governmental agencies beyond the criminal and juvenile court systems are engaged in the task not only of evaluating statistics relating to drug addiction but also of providing informational support and funding for rehabilitation programs. It was not until 1992 that the US Congress mandated the creation of the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the US Department of Health and Human Services. This move stemmed from a rising awareness that millions of substance abuse and mental health cases were being disregarded by the health care system, sometimes because of a person’s inability to pay for assistance and sometimes because of inadequate awareness of what services exist, both in the private and public sectors.

A specific branch of SAMHSA, the Center for Substance Abuse Treatment (CSAT), manages a portion of SAMHSA’s legislatively allotted budget and reviews applications for grants to fund state, local, and private clinics involved in rehabilitation programs. CSAT also provides the general public, professional service providers, and rehabilitation counselors with updated information on substance abuse trends and methods of prevention and treatment.

National statistics (much of its gathered by CSAT) make it possible to compare the availability, staff qualification standards, and application procedures for public and private rehabilitation programs and state-by-state levels of admission to rehabilitation facilities. Among the most developed examples of facilities and individuals in treatment from 2003 through 2013 was California with 11 percent of all facilities and 9 percent of all individuals seeking treatment. New York followed with 6 percent of all facilities and 9 percent of all individuals seeking treatment. Statistics for privately funded rehabilitation programs, which vary considerably both in the number of client-patients admitted and in the nature of therapeutic methods practiced, are less widely circulated.

Missions and Goals

Continuous operation makes it possible to trace short- , medium-, and long-term missions and goals and accomplishments of two major (and internationally recognized) rehabilitation programs: the Odyssey House and Phoenix House.

The Odyssey House, founded in 1967 by psychiatrist Judianne Gerber of New York’s Metropolitan Hospital, pioneered a new approach to rehabilitation, one that hoped to do away with or reduce reliance on drug replacement medications (primarily methadone) in treating patients. Gerber’s, at that time innovative, approach involved founding the first Odyssey House Therapeutic Community (a direction that would be followed almost simultaneously by the Phoenix House movement) in a private building in East Harlem, New York. The first such therapeutic community began with seventeen people seeking to break their drug habit.

In the early 1970s, Odyssey House began to lay plans for two different complementary rehabilitation programs within its overall structure. One involved the establishment, with partial support from public revenue sources, of what was called the Teen Leadership Center. The center combined preventive programs (mainly by offering vocational training and placement services for teens) with special therapy sessions bringing individual drug users (or high-risk youth) together with their families. This latter aspect of the Odyssey House’s approach to rehabilitation has been adopted, depending on available funding and the nature of training undergone by counselors, by many different programs in the United States.

Odyssey House also has gained national recognition for its efforts to structure rehabilitation programs to fit the needs of different age groups and persons with specific family needs. The first of these, a residential center called Mothers and Babies Off Narcotics (MABON) on Ward’s Island, New York, and a second residence in East Harlem were designed to help addicted young parents who were trying to raise their children in a drug-free environment. Since about 1980, the original MABON program has increased its capacity so that it could assist hundreds of mothers and their families. Again, depending on funding, this model has become part of rehabilitation clinics, sometimes as an outpatient procedure, in different states and localities.

Finally, during the 1990s, Odyssey House (by then beginning to expand operations to other regions of the United States) made other changes to meet the needs of specific groups experiencing substance-use dependence. It introduced in situ health-care clinics staffed by certified health practitioners and, in 1997, pioneered the first Odyssey Elder Care rehabilitation program specifically designed to assist drug dependent adults age fifty-five years and older.

Another outstanding and nationally recognized example of a rehabilitation program, Phoenix House, began in a local setting and gradually expanded operations to a number of branch locations nationwide. The initial stimulus came in 1967 from six heroin addicts, all of them participants in a New York City hospital detoxification program, who decided to form their own small community in which they would live together and dedicate themselves to mutual support in their desire to recover from addiction.

The original Phoenix group chose its name to symbolize their faith in the image of the Phoenix, a mythological bird that, in several ancient traditions, is reborn from the ashes after experiencing a long lifecycle and perishing in its own flaming nest. The group received vital support from psychiatrist Mitchell Rosenthal, then deputy commissioner for New York’s Addiction Service Agency.

Despite the wide range of institutional structures, sources of funding, and therapeutic methods used in rehabilitation programs, certain basic features appear to be fundamental to all. One source for understanding developments in the field of drug rehabilitation is the National Association of Alcohol and Drug Abuse Counselors, (NAADAC) founded in 1972. This professional organization exists in addition to a number of state-level associations. The NAADAC’s magazine Counselor, is an excellent reference available not only to association members but also to the public at large to keep informed of issues and therapeutic methods relevant to rehabilitation. For example, news concerning evolving approaches to group (in comparison with individual) therapy and reviews of recently published professional articles appear in the magazine regularly.

Another of NAADAC’s goals is to establish consensus on an unwritten code of ethics applying to relations between rehabilitation professionals and their clients. This can involve, among many other issues, recognizing and knowing how to deal with degrees of empathy or appropriate personal closeness, confidentiality, and avoidance of any form of discrimination, whether ethnic or gender related.

Finally, a primary responsibility for all rehabilitation service providers is to be prepared to refer clients to a different subfield of specialists or medical professionals or to appropriate support systems or community resources that may serve their needs more effectively. Because many such alternative paths are subject to unpredictable changes (owing to dependence on public tax-based funding or renewable grants), those involved in rehabilitation programs must remain closely informed at local, state, and national levels.


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