Appendix: Drug Dependence Treatment Best PracticesIn the past few decades a vast amount of scientific research has been conducted into drug dependence treatment services in many countries around the world. Although there are substantial differences in the nature of the patients treated and in the structure and operation of the treatment system in different countries, the United Nations Office for Drugs and Crime concludes in a 2002 review of the evidence base on effective drug dependence treatment that the findings for the impact of the main forms of structured treatment are remarkably similar across national and cultural divides. On the basis of these similarities, UNODC and several other bodies have formulated a series of basic principles and best practice recommendations for effective drug treatment.244 Below, we provide a summary of these basic principles and best practice recommendations, for which we draw on several overviews of available scientific evidence, including:
Basic Principles of Effective Drug Dependence Treatment Scientific research has shown that observance of a number of basic principles of drug dependence treatment is association with positive treatment outcome.251 NIDA in the United States has formulated a series of 13 principles of effective drug treatment, based on international research. Some of these key principles, which are also at the core of drug dependence treatment protocols in countries like the US, UK, and the Netherlands, are: Drug Dependence is a Chronic and Relapsing Disease One of the most fundamental lessons drawn from the research is the conclusion that drug dependence is a chronic and relapsing disease. For much of the last century, the predominant view of opioid dependence was that it is a self-induced and self-inflicted condition that results from a character disorder or moral failing, and that the condition is best handled as a criminal matter.252 Scientific research has shown this popular beliefwhich maintains currency in many circles even todayto be wrong. Drug dependence has an important biological component that may help explain drug users difficulty in achieving and maintaining abstinence. It is a well established fact that long-term drug use leads to significant changes in brain function that persist long after the individual stops using drugs. These drug-induced changes to brain function may have behavioral consequences, including the compulsion to use drugs despite adverse consequences. This biological component may interact with psychological stress from work or family problems, or social cues (such as meeting individuals from ones drug-using past), to hinder attainment of sustained abstinence and make relapse more likely.253 NIDA therefore concludes that relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning.254 Yet, research also shows that properly designed and implemented treatment programs can achieve similar results to treatment programs for other chronic diseases, such as asthma and diabetes, with treatment success rates of 40 to 60 percent. Treatment Must be Readily Available Research shows that because individuals who are addicted to drugs may be uncertain about entering treatment, it is crucial to take advantage of opportunities when they [drug-dependent people] are ready for treatment.255 Otherwise, [p]otential treatment applicants can be lost. Drug dependence treatment should thus be a low-threshold service without undue obstacles that may keep people out of treatment. Retention of Patients in Treatment for Adequate Period of Time is Critical NIDA observes that although there is no predetermined length of treatment, research has shown unequivocally that good outcomes are contingent on adequate lengths of treatment and that participation [in residential or outpatient treatment] of less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer are often indicated.256 NIDA therefore concludes that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery.257 The Dutch detoxification guideline states that the effectiveness increases with a higher starting dose [of methadone or buprenorphine], a longer tapering period, and adequate attention to psychosocial factors.258 Treatment programs must therefore make efforts to engage patients and keep them in treatment. Treatment Plans Must be Tailored to Individual Patients Needs Research has also consistently shown that no single treatment is appropriate for all individuals. Based on this research, NIDA observes that matching treatment settings, interventions, and services to each individuals particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.259 Thus, individual treatment plans should be developed for each patient that take into account his or her specific needs and problems, as well as his or her age, gender, ethnicity, and culture.260 Treatment guidelines from both the UK and Netherlands strongly emphasize the need for an individual approach to treatment.261 These individual treatment plans should not be static. Research has shown that these plans must be assessed continually and modified as necessary to ensure that the plan continues to meet the persons changing needs. NIDA observes,
The UK Independent Expert Working Group report lists an individual care or treatment plan which is regularly reviewed as one of the essential elements of treatment provision.263 The involvement of the patient in designing the treatment is of crucial importance. UK, US, and Dutch treatment guidelines all stress the need for patient input into the care or treatment plan.264 Research suggests that a therapeutic alliance between patient and therapist or doctora collaboration, requiring agreement on goals and therapeutic tasks, mutual trust, acceptance, confidence, and a rapportis a pan theoretical factor associated with treatment outcomes, across many different modalities and therapeutic approaches to treatment of substance abuse.265 The UK Independent Working Group report states that a therapeutic alliance is crucial to the delivery of any treatment intervention.266 Under the UK treatment system, each patient is assigned a so-called key worker, a healthcare worker with prime responsibility for the patient, and maintains close contact with him or her in order to facilitate the development of a strong therapeutic alliance.267 Treatment Must Attend to Multiple Needs of the Patient Drug dependence is a complex disorder that, as NIDA observes, can involve virtually every aspect of an individuals functioningin the family, at work, in the community.268 Drug users frequently have multiple needsmedical, psychological, social, vocational, or legalat the time they seek treatment. If these problems or needs are not addressed during treatment, they may undermine treatment outcomes. Drug dependence treatment should thus go beyond the patients drug use problem and also address his or her other needs. US, UK, and Dutch treatment guidelines all identify the need to address the various needs of the patient.269 NIDA particularly recommends that the drug dependence treatment system treat drug-dependent persons with coexisting mental disorders, HIV/AIDS, and/or tuberculosis for each of their conditions. It observes that because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the co-occurrence of the other type of disorder.270 As for HIV/AIDS and other health conditions prevalent among drug users, NIDA states that counseling can help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.271 In addition to testing and treatment or blood-borne diseases like HIV and hepatitis C as part of drug dependence treatment, the UK Independent Expert Working Group report emphasizes that reducing potential harm due to overdose should also be a part of all patient care.272 Elements of the Effective Treatment System UNODC describes four phases of drug dependence treatment that can be found in most treatment programs: open access services; detoxification; rehabilitation/relapse prevention; and aftercare. In the words of the UNODC Toolkit, open access services (or street agencies) do not provide formal treatment as such but act as important points of first contact for people who have drug-related problems and for those concerned about drug use of another. The importance of these services is, according to UNODC, hard to overemphasize as they can be a critical place of first contact for drug users who may be reluctant to resort to specialized drug dependence services.273 Open access services include self-help groups, family support groups, drop-in centers, telephone hotlines, and harm reduction programs. These services are often provided by nongovernmental organizations. Many drug-dependent people will face withdrawal symptoms after they stop taking drugs, including abdominal cramps, nausea, vomiting, bone and muscle pain, insomnia, and anxiety. These symptoms generally start within eight to twelve hours and subside over a period of five to seven days. While withdrawal symptoms from drug dependence, unlike alcohol dependence, are not medically dangerous, they can produce intense discomfort.274 The goal of medical detoxification is therefore to help patients achieve withdrawal in as safe and as comfortable a manner as possible.275 This is generally done by providing patients with medications that suppress the withdrawal symptoms or relieve the discomfort they cause. But withdrawing the patient from physical dependence is not the only goal of detoxification treatment. Both the UNODC Toolkit and the NIDA Principles warn that detoxification on its own is not a rehabilitative treatment for drug dependence. The UNODC Toolkit observes that detoxification treatment alone is unlikely to be effective in helping patients achieve lasting recovery; this phase is better seen as a preparation for continued treatment aimed at maintaining abstinence and promoting rehabilitation.276 The Dutch detoxification guidance notes that detoxification is not a goal on its own. Stopping [drug use] is generally not difficult; not relapsing is whats difficult.277 It states that providing detoxification without follow-up treatment is not an inadequate way of treating drug dependence.278 SAMHSAs Treatment Improvement Protocol on detoxification treatment states that it is thus crucially important that patients are counseled during detoxification on the importance of following through with the complete substance abuse treatment continuum of care.279 It further observes that detoxification presents a unique opportunity to intervene during a period of crisis and move a client to make changes in the direction of health and recovery.280 Therefore, a primary goal of the detoxification staff should be to build a therapeutic alliance and motivate the patient to enter treatment. This process should start even as the patient is being medically stabilized.281 As psychosocial factors such as psychological dependence, co-occurring psychiatric and medical conditions, social supports, and environmental conditions critically influence the probability of successful and sustained abstinence from substances, SAMHSA/CSAT states that it is important that these psychosocial factors be addressed already during the detoxification process.282 The UK Independent Expert Working Group report emphasizes that a full programme of psychosocial support needs to be in place during detoxification.283 Indeed, research indicates that addressing psychosocial issues during detoxification significantly increases the likelihood that the patient will experience a safe detoxification and go on to participate in substance abuse treatment.284 Detoxification can be achieved in various different settingsinpatient facilities, community-based facilities, or as an outpatientand at different levels of intensity of care, ranging from limited to intensive medical supervision of the process.285 A number of different medications have been shown to be effective in opioid detoxification, include the opioid methadone, the partial antagonist buprenorphine, and the α2-adrenergic agonists clonidine and lofexidine.286 (Agonists and antagonists both prevent opiates from engaging the brain receptor that they normally bind to. Antagonists do so by blocking that brain receptor, while agonists bind to the receptor so that other substances, like opiates, simply pass it by.) Some inpatient programs use opioid antagonists under sedation or general anesthesia to accelerate the detoxification process. UNODCs Contemporary Drug Abuse Treatment notes that it has been difficult to evaluate the relative merits of these various medications. As for ultrarapid opioid detoxification under sedation or general anesthesia, UNODC states that it has some medical risks and [does] not confer substantial advantage over existing detoxification methods.287 In the TIP on detoxification, SAMHSA/CSAT states that there are few data showing that rapid or ultrarapid methods of opioid detoxification show a positive correlation with likelihood of a patients being abstinent a few months later.288 It lists a range of problems that studies of rapid and ultrarapid detoxification have discovered. Rehabilitation and Relapse Prevention The purpose of rehabilitation or relapse prevention programs is to prevent a return to active substance abuse, assist the patient in developing control over urges to abuse drugs, and assist the patient in regaining or attaining improved personal health and social functioning.289 As drug dependence is a complex disorder that may be caused by different underlying factors in different people and affects peoples lives in different ways, a wide range of treatment strategies and treatments have been developedand shown to be effectiveover the years. The UNODC Toolkit observes that
A comprehensive drug dependence treatment system will offer a broad range of different interventions so that treatment strategies can be tailored to the specific needs of individual patients. The UNODC Toolkit discusses a range of treatments that it says should, ideally, be made available as part of a system of care and rehabilitation. Recognizing that not all states may be in a position to introduce all these elements at once, it recommends a building-blocks approach in which the
The UNODC Toolkit discusses two types of pharmacological interventions that are commonly found in rehabilitation programs: maintenance and antagonist pharmacotherapy. UNODC also lists a large number of different psychosocial interventions in its Toolkit. It notes that patients will often benefit from a combination of various different psychosocial interventions.
Rehabilitation treatment can take place in a number of different treatment settings. Community or day programs are outpatient programs in which patients are provided with psychotherapy or general counseling. Residential rehabilitation programs are inpatient programs of short and long duration, ranging from a month to a full year. Long-term residential rehabilitation programs are often based on a therapeutic community model and usually involve features like communal living with other drug users in recovery, group and individual counseling on relapse prevention, individual case management, improved skills for daily living, training and vocational experience, housing and resettlement services, and aftercare support. Maintenance therapy with Methadone or Buprenorphine Under this treatment modality, a substance like methadone or buprenorphine that is related to the agent that caused the dependence is provided to patients in oral form and under medical supervision. The substance prevents opiate withdrawal, blocks the effects of illicit opiate use, and decreases opiate craving. Once a patient is stabilized on an adequate dose, he or she can function normally.292 Maintenance therapy has been controversial in some countries, with critics expressing concern that patients are not cured of their addiction, that it just replaces one opioid for another, and that it is linked to risks of diversion of opioids. However, a huge body of scientific researchbecause of the controversial nature of these programs no other treatment modality has been so exhaustively and rigorously researchedillustrates beyond any reasonable doubt that maintenance therapy is one of the most effective treatment modalities for opioid drug dependence. The World Health Organization, UNAIDS, and UNODC all support maintenance programs. In a joint position paper on maintenance therapy, the three organizations observed,
Studies have shown that maintenance therapy can achieve high rates of retention in treatment and helps increase the time and opportunity for individuals to tackle major health, psychological, family, housing, employment, financial and legal issues while in contact with treatment services.294 They have also shown that maintenance treatment is safe and cost-effective, and that diversion to the black market, though a real concern, can be minimized through proper implementation of national and international control procedures and other mechanisms.295 The number of countries that use maintenance therapy in drug dependence treatment programs has been increasing steadily over the last few decades. At this writing about 60 countries worldwide, including an increasing number of countries that have significant problems with opioid dependence, have maintenance programs. In recent years, most countries of the former Soviet Union have either introduced maintenance therapy or are conducting or planning maintenance therapy pilot programs, as have a number of countries in the Middle East and Asia. Almost a million opioid drug-dependent people are currently receiving maintenance therapy, including around 237,000 people in North America;296 530,000 in the European Union;297 about 39,000 in Australia;298 about 36,000 in China (which plans to expand its maintenance treatment program considerably);299 and 15,000 in Iran.300 In countries like the UK and the Netherlands, maintenance treatment is the primary form of treatment for opioid dependence.301 Antagonist pharmacotherapy As noted above, this form of treatment involves the prescription of medications that block the euphoric effects of heroin and other opiates on the user, thus preventing him or her from experiencing a high. While these medications are sometimes used as part of relapse prevention treatment, research shows that compliance with antagonist agents is generally poor, except among people who are highly motivated to remain abstinent, and that such programs regularly suffer from high levels of dropout.302 Psychosocial interventions Some of the most common psychosocial interventions include:303
Although not all rehabilitation programs provide for aftercare, the philosophy behind this kind of care is the intention to provide ongoing support to clients at the level required to maintain the earlier benefits and goals. In aftercare, clients may be in regular phone contact with treatment programs, have scheduled or unscheduled appointments, or participate in self-help groups. The Toolkit notes that the effectiveness of such services has not been subject to formal evaluation to date but there is a general commitment to their value and availability.304 244 UNODC, Contemporary Drug Abuse Treatment: A Review of the Evidence Base, p. 1. 245 The publications are: "Investing in Drug Abuse Treatment: A Discussion Paper for Policy Makers"; "Contemporary Drug Abuse Treatment"; and "Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide". All are available on the UNODC website, http://www.unodc.org/unodc/en/treatment_toolkit.html (accessed on April 30, 2007) in English, Spanish, and Russian. 246 NIDA, The Principles of Drug Addiction Treatment: A Research Based Guide. 247 See for example SAMHSA/CSAT, TIP 45, p. vii. 248 National Institute for Health and Clinical Excellence, Drug misuse; Psychosocial interventions, NICE clinical guideline 51, July 2007, http://guidance.nice.org.uk/CG51/niceguidance/pdf/English, and Drug misuse; Opioid detoxification, NICE clinical guideline 52, July 2007, http://guidance.nice.org.uk/CG52/niceguidance/pdf/English (both accessed September 5, 2007). 249 Independent Expert Working Group, Drug misuse and dependence guidelines on clinical management: update 2007. Consultation draft June 2007, http://www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/cgl_update0607/consultation.aspx (accessed September 5, 2007). 250 C.A.J. de Jong, A F.M. van Hoek, M. Jongerhuis, eds., Detoxification Guidance; Responsible detoxification in out- and inpatient settings (Richtlijn Detox; Verantwoord ontgiften door ambulante of intramurale detoxificatie), Geestelijke Gezondheidszorg Nederland, 2004-278, www.ggzkennisnet.nl/ggz/uploaddb/downl_object.asp?atoom=14817&VolgNr=1 (accessed September 5, 2007). 251 NIDA has developed 13 principles of effective drug dependence treatment. The key principles are summarized in this section. For all principles, see The Principles of Drug Addiction Treatment: A Research Based Guide available at http://www.drugabuse.gov/PDF/PODAT/PODAT.pdf. 252 SAMHSA/CSAT, TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, p. 8. 253 NIDA, The Principles of Drug Addiction Treatment: A Research Based Guide, pp. 12-13. 254 Ibid., principle 13, p. 5. 255 Ibid., principle 2, p. 3. 256 Ibid., p. 16. 257 Ibid., principle 5, p. 3. 258 De Jong, Van Hoek, Jongerhuis, eds., Detoxification Guidance; Responsible detoxification in out- and inpatient settings, p. 23. 259 Ibid., principle 1, p. 3. 260 Ibid., principle 4, p. 3. 261 The Dutch treatment guideline states, An individualized plan for detoxification is drafted. There are major individual differences between patients in terms of signs and symptoms as a result of withdrawal. A detoxification plan that is tailored to the patient provides the best chance of success. De Jong, Van Hoek, Jongerhuis, eds., Detoxification Guidance; Responsible detoxification in out- and inpatient settings, p. 13; Independent Expert Working Group, Drug misuse and dependence guidelines on clinical management: update 2007. Consultation draft June 2007, pp. 51-52 262 Ibid. 263 Independent Expert Working Group, Drug misuse and dependence guidelines on clinical management: update 2007. Consultation draft June 2007, p. 47. The report also states that the care or treatment plan should be agreed with the patient, and should normally cover patient need as identified in one or more of the following domains: drug and alcohol use; physical and psychological health; criminal involvement; and social functioning (pp. 51-52). 264 Ibid., pp. 51-52; and De Jong, Van Hoek, Jongerhuis, eds., Detoxification Guidance; Responsible detoxification in out- and inpatient settings, p. 13. 265 Elovich, Drug Demand Reduction Programs Treatment and Rehabilitation Improvement Protocol, p. 16. 266 Independent Expert Working Group, Drug misuse and dependence guidelines on clinical management: update 2007. Consultation draft June 2007, p. 64. 267 Ibid., pp. 53 and 68. 268 NIDA, The Principles of Drug Addiction Treatment: A Research Based Guide, p. 23. 269 National Institute for Health and Clinical Excellence, Drug misuse; Opioid detoxification, p. 10; De Jong, Van Hoek, Jongerhuis, eds., Detoxification Guidance; Responsible detoxification in out- and inpatient settings, p. 153. 270 NIDA, The Principles of Drug Addiction Treatment: A Research Based Guide, principle 8, p. 4. 271 Ibid., principle 12, p. 5. 272 Independent Expert Working Group, Drug misuse and dependence guidelines on clinical management: update 2007. Consultation draft June 2007, p. 120. 273 UNODC, "Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide," chapter 4, p. IV.2. 274 SAMHSA/CSAT, TIP 45, p. 66. 275 UNODC, "Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide, p. IV.2. 276 UNODC, Contemporary Drug Abuse Treatment: A Review of the Evidence Base; and NIDA Principles of Effective Drug Addiction Treatment; A Research-Based Guide, principle 9. 277 De Jong, Van Hoek, Jongerhuis, eds., Detoxification Guidance; Responsible detoxification in out- and inpatient settings, p. 8. 278 Ibid., p. 153. 279SAMHSA/CSAT, TIP 45: Detoxification and Substance Abuse Treatment, pp. 4- 5. This motivational work is one of the three essential components of detoxification described in SAMHSAs Treatment Improvement Protocol on detoxification, which describes it as preparing the patient to enter into substance abuse treatment by stressing the importance of following through with the complete substance abuse treatment continuum of care. 280 Ibid., p. 23. 281 Ibid. 282 Ibid. 283 Independent Expert Working Group, Drug misuse and dependence guidelines on clinical management: update 2007. Consultation draft June 2007, p. 107. 284 Ibid. 285 In the United States, for example, health facilities use five levels of intensity of care for detoxification for substance dependence, ranging from outpatient detoxification without significant medical supervision to intensive inpatient detoxification. Level I-D: Ambulatory Detoxification without Extended Onsite Monitoring; Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring; Level III-D: Clinically Managed Residential Detoxification; Level IV-D: Medically Monitored Inpatient Detoxification; Level V-D: Medically Managed Intensive Inpatient Detoxification. 286 The UK and Netherlands treatment protocols reviewed for this report recommend methadone and buprenorphine as first-line medications for opioid detoxification. The UK treatment guideline advises against the use of clonidine for opioid detoxification treatment because of side effects. National Institute for Health and Clinical Excellence, Drug misuse; Opioid detoxification, p. 14. 287 UNODC, Contemporary Drug Abuse Treatment: A Review of the Evidence Base, p. 3. 288 SAMHSA/CSAT, TIP 45, p. 73. The UK clinical guidance on opioid detoxification also advises against the use of rapid and ultra-rapid detoxification because of health risks associated with some of these forms of detoxification and the high levels of nursing and medical supervision required. National Institute for Health and Clinical Excellence, Drug misuse; Opioid detoxification, p. 16. 289 UNODC, Contemporary Drug Abuse Treatment: A Review of the Evidence Base, p. 5. 290 Ibid. 291 UNODC, Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide, p. IV.1. 292 NIDA, Principles of Effective Drug Addiction Treatment: A Research-Based Guide, p. 24. 293 WHO/UNODC/UNAIDS, Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention, p. 13. 294 Ibid. 295 Ibid. 296 Office of Applied Studies, United States Substance Abuse and Mental Health Services Administration, Facilities Operating Opioid Treatment Programs: 2005. Drugs and Alcohol Services Information System. 297 Schering-Plough Market Access data, Sept 2006, Suboxone Access Situational Analysis 070302, Presentation at the International Harm Reduction Association Conference, Warsaw, Poland, May 15, 2007. 298As of June 30, 2005, excluding data for South Australia and the Australian Capital Territory. Australian Institute of Health and Welfare, Statistics on drug use in Australia 2006, Drug statistics series no. 18, April 12, 2007 http://www.aihw.gov.au/publications/phe/soduia06/soduia06-c01.pdf, p. 69. (Accessed July 12, 2007). 299 Wu Zunyou and Zhao Chenghong. "Update of Harm Reduction in China," Presentation at the International Harm Reduction Association Conference, East to East Panel, May 13, 2007, http://www.china.org.cn/english/news/203131.htm, accessed July 15, 2007. 300 International Experts Call for Greater Commitment to Opiate Substitution Treatment, International Center for the Advancement of Addiction Treatment. 301 See, for example, National Institute for Health and Clinical Excellence, Drug misuse; Psychosocial interventions, p. 4. 302 NIDA, Principles of Effective Drug Addiction Treatment: A Research-Based Guide, pp. 35-48. 303 Detailed information on these and other psychosocial interventions can be found in, among others, NIDA, Principles of Effective Drug Addiction Treatment: A Research-Based Guide, pp. 35-48, and National Institute for Health and Clinical Excellence, Drug misuse; Psychosocial interventions. 304 UNODC, "Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide," p. IV.5. |