Addiction is characterized by persistent use of a drug despite negative consequences. Over the past few decades, extensive research has supported the medical model which refers to addicti on as a "primary, chronic disease of brain reward, motivation, memory, and related circuitry"1. SUDs exist on a spectrum of severity, depending on the number of criteria met2. Clinical approaches to treating these disorders have ranged from pharmacological, psychotherapeutic, and psychosocial interventions discussed below.
These days, the first-line treatments for SUDs, especially those of alcohol or opioid use disorder, are pharmacological in nature (Connery, 2015). These are often referred to as maintenance therapies or medicationassisted treatments (MATs) and are used to 1) treat symptoms of withdrawal and 2) attenuate cravings, thereby decreasing likelihood of relapse3 4.
Non-pharmacological interventions are often paired with medication-based treatments and are largely psychosocial in nature. These include motivational interviewing, behavioral therapies (e.g. cognitive-behavioral therapy, dialectical behavioral therapy, contingency management), psychodynamic psychotherapies, and self-help groups (e.g. alcoholic/narcotics anonymous, 12-step peer-programs)5 1.
Other non-pharmacological interventions that have been proven to reduce complications associated with drug-use include harm-reduction strategies. For example, clean-needle exchange programs and safe-injection sites have been proven to reduce transmission of infectious diseases, thereby reducing the clinical and economic burden associated with SUDs 6. Naloxone distributions, also known as opioid reversal agents, are also proven to be effective in reducing the mortality associated with opioid overdoses 7 8 9 10. Both are non-associated with increased use or frequency of use, thereby making them important inclusions of an integrative treatment approach 11 12.
For the more impaired patient population who need acute and intensive support, detoxification centers and residential rehabilitation centers are utilized. These include relatively short-term, inpatient stays intended to support temporary stabilization 13. However, it is unclear the efficacy of short-term rehabilitation programs in the larger scheme of an individual’s recovery. It is suggested that many are discharged from such centers prematurely, which might lead to increases in hospital and/or emergency room visits 14 15. Despite the high numbers of short-term centers across the world, research indicates that increased lengths of stay predict better prognosis, including lower readmission rates, decreased symptomatology, and better psychosocial functioning 16 17 18 19.
There are, however, individuals who continue substance use despite engagement in the aforementioned treatments. They are often considered the more severe population of SUDs and typically include those who are involved in the legal system, unemployed, with interpersonal dysfunction, and/or considered treatment resistant (e.g. poor response to treatments) 20 21. These patients are thought to particularly benefit from the integrated approach of the TC model which is discussed in Historical Note on Therapeutic Communities. However, it has been observed that an early detection and treatment with a TC approach for young people with SUDs can prevent a progression into further deterioration of their lifestyles, therefore preventing a chronic disorder and the development of physical and mental health issues.
- 1. a. b. Rastegar, D., & Fingerhood, M. (2015). The American Society of Addiction Medicine Handbook of Addiction Medicine. Oxford University Press.
- 2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
- 3. Volkow, N. D. (2018). Medications for opioid use disorder: bridging the gap in care. The Lancet, 391(10118), 285-287.
- 4. Lee, J., Kresina, T. F., Campopiano, M., Lubran, R., & Clark, H. W. (2015). Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. BioMed research international, 2015.
- 5. Avery, J. D., & Barnhill, J. W. (Eds.). (2017). Co-occurring mental illness and substance use disorders: a guide to diagnosis and treatment. American Psychiatric Pub.
- 6. Galanter, M., Kleber, H. D., & Brady, K. (Eds.). (2014). The American Psychiatric Publishing textbook of substance abuse treatment. American Psychiatric Pub.
Volkow, N. D. (2018). Medications for opioid use disorder: bridging the gap in care. The Lancet, 391(10118), 285-287.
- 7. Maxwell, S., Bigg, D., Stanczykiewicz, K., & Carlberg-Racich, S. (2006). Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. Journal of addictive diseases, 25(3), 89-96.
- 8. Seal, K. H., Thawley, R., Gee, L., Bamberger, J., Kral, A. H., Ciccarone, D., ... & Edlin, B. R. (2005). Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study. Journal of Urban Health, 82(2), 303-311.
- 9. Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., ... & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. Bmj, 346, f174.
- 10. Doe-Simkins, M., Quinn, E., Xuan, Z., Sorensen-Alawad, A., Hackman, H., Ozonoff, A., & Walley, A. Y. (2014). Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health, 14(1), 297.
- 11. Volkow, N. D., Jones, E. B., Einstein, E. B., & Wargo, E. M. (2019). Prevention and treatment of opioid misuse and addiction: a review. JAMA psychiatry, 76(2), 208-216.
- 12. Adams, J. M. (2018). Increasing naloxone awareness and use: The role of health care practitioners. Jama, 319(20), 2073-2074.
- 13. Miller, M. M. (1998). Traditional approaches to the treatment of addiction. Principles of addiction medicine.
- 14. Konstantopoulos, W. L. M., Dreifuss, J. A., McDermott, K. A., Parry, B. A., Howell, M. L., Mandler, R. N., ... & Weiss, R. D. (2014). Identifying patients with problematic drug use in the emergency department: results of a multisite study. Annals of emergency medicine, 64(5), 516-525.
- 15. Rockett, I. R., Putnam, S. L., Jia, H., Chang, C. F., & Smith, G. S. (2005). Unmet substance abuse treatment need, health services utilization, and cost: a population-based emergency department study. Annals of emergency medicine, 45(2), 118-127.
- 16. De Leon, G. (1985). The therapeutic community: Status and evolution. International Journal of the Addictions, 20(6-7), 823-844.
- 17. De Leon, G. (2015). "The Gold Standard" and related considerations for a maturing science of substance abuse treatment. Therapeutic Communities; a case in point. Substance Use & Misuse, 50(8-9), 1106-1109.
- 18. Hubbard, R. L., Cavanaugh, E. R., Craddock, S. G., & Rachal, J. V. (1985). Characteristics, behaviors, and outcomes for youth in the TOPS. Treatment services for adolescent substance abusers, 49-65.
- 19. Sells, S. B., & Simpson, D. D. (1979). Evaluation of treatment outcome for youths in the Drug Abuse Reporting Program (DARP): A follow-up study. Youth drug abuse: Problems, issues, and treatment, 571-628.
- 20. Dye, M. H., Roman, P. M., Knudsen, H. K., & Johnson, J. A. (2012). The availability of integrated care in a national sample of therapeutic communities. The journal of behavioral health services & research, 39(1), 17-27.
- 21. Vanderplasschen, W., Colpaert, K., Autrique, M., Rapp, R. C., Pearce, S., Broekaert, E., & Vandevelde, S. (2013). Therapeutic communities for addictions: a review of their effectiveness from a recovery-oriented perspective. The Scientific World Journal, 2013.