Substance Use Disorder Treatment Approaches

Many people who use substances be it drugs or alcohol may ask, ‘will treatment work?’ and the simple answer is yes, treatment works.

It has been shown that treatment for substance use can improve the lives of the people who are using drugs and alcohol, their families, and their communities. There are however many different approaches to treatment, and which approach is best to use will depend primarily on the needs of the person, the treatment provider, and the treatment services available (1).

Prevention Programmes

Perhaps before we discuss treatments it would be good to also mention prevention. In healthcare it is well known that prevention is better than cure. In substance use there are different approaches to prevention; these include:

• prevention programmes that target society as a whole called environmental or universal prevention programmes
• programmes that focus on specific individuals with specific risks, known as indicated prevention programmes.

It is important to use an appropriate prevention programme for the group or individual you are working with and to ensure it has been evaluated as effective. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) publishes details of programmes addressing drug and alcohol use that have been tested and proven to be effective (2). Prevention programmes that have been shown to be ineffective can have negative consequences.

Treatment Approaches

When deciding on a treatment approach, the needs and treatment goals of the person seeking treatment should be a deciding factor. However, the person using the substances may not be aware of the different approaches available to them. Treatment approaches can also be called treatment modalities, and these can range from abstinence-based programmes to harm reduction and recovery.

Abstinence Approach

For some treatment services, abstinence can mean not using any drugs or alcohol, while for others abstinence is not using the specific substance that has caused the person a problem. Treatment for substance use based on abstinence approaches will often involve a detoxification stage followed by a longer supervised period of abstinence and possibly rehabilitation. While there is little evidence to support the long-term effectiveness of detoxification, there is increasing evidence to support the effectiveness of abstinence-based treatments if they are of sufficient duration.

Harm Reduction Approach

There has been a rapid increase in the number of deaths and a huge spread of HIV, AIDS, and Hepatitis C globally from the 1980s to the present day among people who inject drugs. This has highlighted the need to move away from abstinence-based treatments and move towards harm reduction treatments. The International Harm Reduction Association defines harm reduction as, ‘…policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption’. A harm reduction approach refers to programmes and practices that aim to minimise the negative health outcomes of drug or alcohol use, while also reducing or eliminating the social consequences for people who use prohibited substances through drug policies and drug laws. Harm reduction targets the causes and the harms and aims to address these causes at a population or individual level. It relates to public health and human rights-based approaches. An integral part of harm reduction programmes is to treat people who use drugs or alcohol, their families and communities with compassion and dignity. This is considered a human right.

Recovery Treatment Approach

While the harm reduction approach has been praised as being responsible for saving lives globally, it has also been criticised for its failure to address wider issues related to substance use and the re-integration of people into society. The recovery treatment approach has evolved from one which originally was fully abstinence based to one which now accepts that recovery is no longer universally defined but rather is defined for and by the individual in recovery. Recovery is seen as a process rather than as an end state. With this definition of recovery, an individual may or may not achieve a state of abstinence. For example, for a mother who uses drugs or alcohol and has lost the care of a child, recovery may mean a reduction in substance use and the gaining of the care of her child.

In the words of one grandparent watching her daughter recover:

‘“Addiction is one thing, but recovery is another journey completely. I want people to know how scary, how fragile and how fearful recovery is. It’s awful. You need to be aware of the absolute fragility of recovery. …This doesn’t mean that people don’t recover because they do. One piece of advice for parents, never give up on your child.”

Regardless of the treatment approach, access to appropriate treatment for people who use substances and the stage they are at in their personal journey remains the crucial element. Unfortunately, access to treatment, treatment coverage and best practice within services is not universally available. While we can measure global treatment coverage, little is known about the quality of treatment provided or if these treatments are adhering to the standards of best practice (3).

Many people who use substances do not need treatment, and some of those experiencing problems associated with their use, may be unwilling or unable to enter an abstinence-based treatment for reasons we will learn about throughout the course. While abstinence from drug or alcohol use may be the end goal for some people who use substances, the human rights of the individual to express their treatment preferences must also be considered. Harm reduction provides an evidence-based approach for health care, and treatment programs while respecting the individual’s right to choose.

Discussion

As a practitioner or researcher what treatment philosophies does your practice include?

References

<sup>1. Comiskey C, Kelly P, Leckey Y, McCullough L, O’duill B, Stapleton R, et al. The ROSIE study: Drug treatment outcomes in Ireland: Stationery Office; 2009.
2. Comiskey C. Reducing Harm, Supporting Recovery: a partnership and evidence-informed approach to developing the new Irish health led, National Drug Strategy. Harm Reduction Journal. 2020;17(1).
3. Comiskey C. Addiction debates: Hot topics from policy to practice: SAGE; 2019.</sup>