What Is Evidence-Based Addiction Treatment, Anyway?
Last month, The National Center on Addiction and Substance Abuse (CASA) at Columbia University released a five-year study assessing the state of addiction treatment in the U.S. Among other findings, CASA reported that only one in 10 people in need of addiction treatment get it, and of those who do, most “do not receive anything that approximates evidence-based care.”
Evidence-based care does exist in a minority of treatment centers, but how does one go about finding it? What exactly is evidence-based care? In short, evidence-based care is treatment that is backed by scientific research. According to CASA, it includes the following elements:
Comprehensive Assessments – To understand each individual’s specific needs, CASA advises physicians and other health professionals to complete a comprehensive assessment. This assessment should evaluate the individual’s medical, psychological, social, family and substance use history, current health status, addictive behaviors, personality traits, and the presence of any co-occurring disorders.
Based on this assessment, the team develops an individualized treatment plan that contains specific goals and interventions. As the patient’s needs change, the treatment plan is revised accordingly.
Stabilization – The initial goal of treatment is to eliminate the use of drugs and alcohol. The stabilization phase, also known as detoxification, may include drug tests, assessments, and medications to minimize drug cravings and symptoms of withdrawal. Unless the individual is not physically dependent on drugs, is in the early stages of the disease and has a personal support system, detox typically requires medical supervision to ensure safety. Detox itself is not treatment, but rather the start of a longer recovery process.
Acute Care – There is no single approach that is effective for all addicts. Studies show that the most effective treatment includes a combination of pharmaceutical and psychosocial therapies, tailored to the needs of the individual. Research supports the following therapies, among others:
• Motivational Interviewing: Often used with patients who feel ambivalent or resistant to sobriety, this technique bolsters their motivation to change and helps them stay committed to treatment.
• Cognitive-Behavioral Therapy: In CBT, patients develop social and problem-solving skills and tools for stress management, which help change the thoughts and behaviors that contribute to addictive patterns.
• Community Reinforcement Approach: This form of therapy focuses on life skills, family relations, recreational activities and vocational skills that can minimize the drive to use drugs and alcohol.
• Contingency Management: This intervention is designed to reward positive behavior through incentives for reaching treatment goals.
• Couples/Family Therapy: Patients work with their families to improve communication and reduce conflict. Programs that emphasize family involvement tend to have higher retention rates and are more effective than programs that treat the addict alone.
• Nutrition and Exercise: A healthy diet and regular exercise can enhance treatment outcomes, reduce cravings, relieve symptoms of anxiety and depression, and repair nutritional imbalances that result from addiction.
Chronic Disease Management – All too often, addiction treatment ends after acute care. As a chronic illness, research shows that long-term success requires long-term care. Disease management helps patients function in daily life, manage stress and co-occurring conditions, and reduce the threat of relapse. In appropriate cases, medically supervised maintenance therapy may be a useful strategy in chronic disease management. Other elements of long-term care may include:
• Case Management: Case managers make sure patients receive the services they need by providing referrals, coordinating peer and family support services, and promptly intervening in the event of relapse. Studies associate case management with an increased chance that people will get and stay in treatment.
• Support Services: CASA describes self-help groups, such as Alcoholics Anonymous, as a “significant part” of a comprehensive treatment approach that has proven “lifesaving and critical” to helping patients manage their disease. These groups are widely available and frequently accessed, with research showing they improve psychological functioning and reduce substance abuse. Other research has found that those who participate in a 12-Step group following treatment have about twice the rate of abstinence as those who do not participate. Other useful support services may include therapeutic communities, sober living houses, and programs that address legal, employment, housing and parenting issues.
One of the most effective models we have for long-term disease management is the physician health program (PHP), a model Promises has long embraced. The PHP works with addicted physicians to find ongoing support services, provides case management and refers physicians to reputable treatment centers that provide intensive, long-term care.
Physicians are monitored through drug tests and other means to ensure compliance, often up to five years after formal treatment ends. Physicians who violate the terms of their contingency management agreements expose themselves to negative consequences, such as loss of their license and disciplinary actions. Studies show that more than 80 percent of physicians who participate in PHPs return to work and remain drug-free for at least five years following treatment.
A Comprehensive Approach – Treatment should not focus on one specific addictive drug, but rather the full range of substances and behaviors associated with addiction. This includes addictive patterns surrounding food, gambling, sex and other compulsive behaviors.
Multidisciplinary Treatment Team of Qualified Professionals – In many addiction treatment programs, services are provided by addiction counselors who have minimal education and training. As a medical illness, CASA asserts that addiction treatment should be provided by a multidisciplinary team that also includes physicians, nurses and graduate-level mental health professionals. Having a physician on staff, along with well-educated clinicians, allows programs to provide the full range of evidence-based treatments.
CASA’s finding that addiction treatment in the U.S. is largely inadequate does not mean that treatment doesn’t work. Addiction can be treated effectively if individuals choose a program that provides evidence-based care. Until we have standards and best practices in place nationwide, they may not be easy to find, but they do exist – and hopefully more will join the ranks as demand for quality care grows.
David Sack, M.D., is board certified in Addiction Medicine and Addiction Psychiatry. As CEO of Elements Behavioral Health he oversees a network of addiction treatment programs that include Promises, The Ranch, The Sexual Recovery Institute, and The Recovery Place.
Whiskey photo available from Shutterstock
Sack, D. (2012). What Is Evidence-Based Addiction Treatment, Anyway?. Psych Central. Retrieved on May 29, 2015, from http://blogs.psychcentral.com/addiction-recovery/2012/07/evidence-based-addiction-treatment/