publications

III. Drug Dependence Treatment Best Practices

Findings of scientific research in the field of drug dependence treatment, and best practice standards formulated on the basis of that research, provide an invaluable framework against which to judge the drug dependence treatment system of a given country. They provide the necessary insights to assess what types of services a state needs to offer, how these services must be offered, and what services are of good quality and medically and ethically appropriate.

In 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.”89 On the basis of these similarities, UNODC, various national health agencies, and several other bodies have formulated a series of basic principles and best practice recommendations for effective drug treatment, which are summarized below.90 A more detailed presentation of these can be found in the Appendix to this report.

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.91 Some of these key principles are:

Drug Dependence is a Chronic and Relapsing Disease

The predominant view of much of the last century—that opioid dependence 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”—is wrong.92 According to the US National Institute for Drug Abuse (NIDA), “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…”93 Nonetheless, 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

Individuals who are addicted to drugs may be uncertain about entering treatment. It is thus crucial to “take advantage of opportunities when they [drug-dependent people] are ready for treatment” so potential patients are not lost.94

Retention of Patients in Treatment for Adequate Period of Time is Critical

Research has found that good outcomes are contingent on adequate lengths of treatment and that “participation of less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer are often indicated.”95

Treatment Plans Must be Tailored to Individual Patients’ Needs

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. Research has consistently shown that no single treatment is appropriate for all individuals.96 Individual treatment plans should be assessed continually and modified routinely to ensure that the plan continues to meet the person’s changing needs. Patients should be involved in designing the treatment, as research suggests that a “therapeutic alliance” between patient and therapist or doctor—a collaboration, requiring agreement on goals and therapeutic tasks, mutual trust, acceptance, confidence, and a rapport—is a crucial factor in treatment outcomes.97

Treatment Must Attend to Multiple Needs of the Patient

Drug dependence can involve virtually every aspect of an individual’s functioning—in the family, at work, in the community—and drug users frequently have multiple needs—medical, psychological, social, vocational, or legal—at the time they seek treatment. 98 If these problems or needs are not addressed during treatment, they may undermine treatment outcomes. Drug dependence treatment should thus go beyond the patient’s drug use problem and also address his or her other needs, including by providing treatment for coexisting mental disorders, HIV/AIDS, and tuberculosis.99,100

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.

Open Access Services

These services “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.” They are a “critical place” of first contact for drug users who “may be reluctant to resort to specialized drug dependence services.”101 Open access services include self-help groups, family support groups, drop-in centers, telephone hotlines, and harm reduction programs.

Detoxification Treatment

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. The goal of medical detoxification is to help patients “achieve withdrawal in as safe and as comfortable a manner as possible.”102 This is generally done by providing patients with medications that suppress the withdrawal symptoms or relieve the discomfort they cause.

But detoxification on its own is not a rehabilitative treatment for drug dependence. The UNODC “Drug Dependence Treatment 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.”103 Detoxification treatment protocols in the US state 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” and that “a primary goal of the detoxification staff should be to build a therapeutic alliance and motivate the patient to enter treatment.”104 This process should start even as the patient is being medically stabilized.105

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,it is important that these factors be addressed already during the detoxification process.106Indeed, 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.”107

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 to “assist the patient in regaining or attaining improved personal health and social functioning.”108As drug dependence is a complex disorder that may be caused by different underlying factors in different people and affects people’s lives in different ways, a wide range of treatment strategies and treatments has been developed—and shown to be effective—over the years.  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. 109

The UNODC Toolkit discusses two types of pharmacological interventions that are commonly found in rehabilitation programs: maintenance and antagonist pharmacotherapy. Maintenance treatment is discussed below. Antagonist pharmacotherapy 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.110

The Toolkit also lists a large number of different psychosocial interventions. It notes that patients will often benefit from a combination of various different interventions. Some of the most common psychosocial interventions include: cognitive-behavioral therapy, supportive-expressive psychotherapy, individualized drug counseling, and motivational enhancement therapy.111

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.112

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 with another, and that it is linked to risks of diversion of opioids. However, a huge body of scientific research illustrates 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,

There is consistent evidence from numerous controlled trials, longitudinal studies and programme evaluations, that substitution maintenance therapy for opioid dependence is associated with generally substantial reductions in illicit opioid use, criminal activity, deaths due to overdose, and behaviors with a high risk of HIV transmission.113

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.”114 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.115

The number of countries that use maintenance therapy in drug dependence treatment programs has been increasing steadily over the past 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 several 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;116 530,000 in the European Union;117 about 39,000 in Australia;118 about 36,000 in China (which plans to expand its maintenance treatment program considerably);119 and 15,000 in Iran.120 In countries like the United Kingdom and the Netherlands, maintenance treatment is the primary form of treatment for opioid dependence.121

Aftercare Stage

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.122




89 UNODC, Contemporary Drug Abuse Treatment: A Review of the Evidence Base (Vienna, United Nations International Drug Control Program, 2002), p. 1.

90 For this section, we have drawn on the “Treatment and Rehabilitation Toolkit,” published by UNODC in 2002, available on the UNODC website, http://www.unodc.org/unodc/en/treatment_toolkit.html (accessed April 30, 2007); the “Principles of Drug Addiction Treatment; A Research Based Guide,” published by the United States National Institute on Drug Abuse (NIDA) of the National Institutes of Health, http://www.drugabuse.gov/PDF/PODAT/PODAT.pdf (accessed April 30, 2007); several Treatment Improvement Protocols (TIPS) published by the Center for Substance Abuse Treatment (CSAT, an institution of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the US Department of Health and Human Services), which can be found at http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.part.22441 (accessed July 27, 2007); clinical guidelines of the United Kingdom National Institute for Health and Clinical Excellence on opioid detoxification and psychosocial interventions, available at http://guidance.nice.org.uk/CG51/niceguidance/pdf/English  and http://guidance.nice.org.uk/CG52/niceguidance/pdf/English (both accessed September 5, 2007); the 2007 consultation draft of a report of the UK Independent Expert Working Group on clinical guidelines on drug misuse and dependence, available at http://guidance.nice.org.uk/CG52/niceguidance/pdf/English (accessed September 5, 2007); and the detoxification guidance of the Netherlands Institute for Mental Health (Geestelijke Gezondheidszorg Nederland), available at www.ggzkennisnet.nl/ggz/uploaddb/downl_object.asp?atoom=14817&VolgNr=1 – (accessed September 5, 2007).

91 NIDA has developed 13 principles of effective drug dependence treatment. The key principles are summarized in this section. For all principles, see NIDA, “Principles of Drug Addiction Treatment: A Research-Based Guide.” These key principles are also at the base of national treatment guidelines  in countries like the United States, the United Kingdom, and the Netherlands.

92 SAMHSA/CSAT, TIP 43, p. 8.

93 NIDA, “Principles of Effective Drug Addiction Treatment: A Research-Based Guide.”

94 Ibid., principle 2.

95 Ibid., p. 16.

96 Ibid., principle 4.

97 R. Elovich, “Drug Demand Reduction Program’s Treatment and Rehabilitation Improvement Protocol,” DDRP, a Project of USAID, p. 16. A copy is on file with Human Rights Watch.

98 NIDA, “Principles of Effective Drug Addiction Treatment: A Research-Based Guide,” p. 23.

99 Ibid., principle 8.

100 Ibid., principle 12.

101 UNODC, "Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide," UN E.03.XI.II, 2003, www.unodc.org/pdf/report_2003-07-17_1.pdf (accessed August 28, 2007), Chapter 4, p. IV.2.

102 Ibid.

103 UNODC, “Contemporary Drug Abuse Treatment: A Review of the Evidence Base”; NIDA, “Principles of Effective Drug Addiction Treatment; A Research-Based Guide,” principle 9.

104 This motivational work is one of the three “essential components” of detoxification described in SAMHSA’s 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.SAMHSA/CSAT, “Detoxification and Substance Abuse Treatment,” TIP 45, pp. 4- 5, 23

105 Ibid.

106 Ibid.

107 Ibid.

108 UNODC, “Contemporary Drug Abuse Treatment: A Review of the Evidence Base,” p. 5.

109 UNODC, “Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide,” p. IV.1.

110 Ibid., p. IV.5.

111 NIDA, “Principles of Effective Drug Addiction Treatment: A Research-Based Guide,” pp. 35-48.

112 Ibid., p. 24.

113 World Health Organization (WHO), United Nations Office on Drugs and Crime (UNODC), Joint United Nations Programme on HIV/AIDS (UNAIDS), Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention (Geneva: 2004), p. 13.

114 Ibid., p. 13.

115 Ibid., pp. 20, 32.

116 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, Issue 36, 2006, http://www.oas.samhsa.gov/2k6/OTP/OTP.htm (accessed July 18, 2007).

117 Schering-Plough Market Access data, September 2006, “Suboxone Access Situational Analysis 070302,” presentation at the International Harm Reduction Association Conference, Warsaw, Poland, May 15, 2007.

118As 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 (accessed July 12, 2007), p. 69.

119  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).

120 “International Experts Call for Greater Commitment to Opiate Substitution Treatment” , International Center for the Advancement of Addiction Treatment, Press Release, October 25, 2006.

121 See, for example, National Institute for Health and Clinical Excellence, “Drug misuse; Psychosocial interventions,” p. 4.

122 UNODC, “Drug Abuse Treatment and Rehabilitation. A Practical Planning and Implementation Guide,” p. IV.5.