“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”
– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

“Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs.”
– National Institute on Drug Abuse (NIDA), a division of the National Institutes of Health (NIH), 2018

Treatment Plan Goal: To assist individuals in living healthy, functional lives, in connection with others, such that substance use does not result in negative consequences for themselves, others, or society.

Objectives listed in priority order:

1 – Medical Care

• Physical exam and diagnostic lab work
• Assessment for suitability for medications for:
  – Substance use disorders (SUDs), including nicotine replacement therapy
  – Co-occurring mental illnesses
  – Physical illnesses
  – Physical pain
  – Sleep disturbances
  – Nutrition and diet
  – Assessment for neuroatypicality: sensory sensitivity and under-sensitivity (Unbroken Brain, Chapter 4); attention challenges; autism spectrum
• Assessment for suitability for follow-up care, additional treatment, and referrals

2 – Mental Health Care

Mental Health Assessment

• Trauma (2/3 of all people with SUDs have experienced trauma)
• Co-occurring mental illnesses (over 1/2 of all people with SUDs have at least one co-occurring mental illness)
• Current stressors
• Needs assessment

Counseling

• Individual counseling: cognitive behavior therapy (CBT) and a form of CBT, dialectical behavior therapy (DBT)
• Skills-based group counseling (General group counseling is not evidence-based to result in decreased substance use.)
• Relationship skills (Given the neurocircuitry of attachment/bonding/love and addiction, the more individuals are able to skillfully manage connecting, engaging, attuning, and attaching with both themselves and others, the more likely they are to abstain from illicit or non-prescribed substances.)
• Assessment of the function and meaning of substances and substance use

3 – Support Services

• Connect individuals with social services agencies to assist with current stressors and needs: employment, housing, transportation, child care, legal issues, etc.
• Income: Assist individuals with finding jobs or applying for disability benefits.

4 – Social Support

• Interests and preferences assessment
• Experimentation with diverse interest groups, clubs, religious groups, support groups and/or other sources of social connection based on individual interests and preferences

. . . . .

The content of this treatment plan is based on a synthesis of extensive literature reviews that I and Laurel Sindewald have conducted on substance use disorders and their treatment. The treatment plan is highly informed by Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, released in November, 2016.

The Surgeon General’s Report is current as of November, 2016, with these exceptions: In terms of treatment effectiveness, research data does not support inclusion of 12-step approaches or rehab, nor does it support inclusion of naltrexone, or extended release naltrexone, as a primary treatment for opioid use disorder, equivalent to methadone and buprenorphine. Naltrexone may be contraindicated for those with liver disease and can be associated with depression. According to Buchel et al., November, 2018, “blocking opioid receptors decreases the pleasure of rewards in humans.”

We link to primary sources reporting research data as available, and authoritative secondary sources that cite multiple primary sources. Our reports are here. Since nearly every word in this post could be linked to a source, I have only linked to sources for terms or concepts that may be unfamiliar to some. Feel free to contact me with questions or feedback.

The goal of substance use disorder treatment is to assist individuals with living healthy, functional lives, in connection with others, such that substance use does not result in negative consequences for themselves, others, or society. A treatment plan describes how a person hopes to reach this goal, or to get help with reaching this goal, through specific steps, termed objectives.

Above is a brief outline of evidence-based treatment components for an individual beginning treatment for substance use disorder.  This treatment plan is evidence-informed, not evidence-based, because it, as a stand-alone protocol, has not been subject to research.

I define evidence-based treatment as what research reports works for most people, most of the time, better than other treatments, and better than no treatment. Specifically, that means the treatment is supported by numerous, peer-reviewed scientific experiments with rigorous methods that include control groups, randomization of subjects to experimental conditions, and bias-free samples, with statistically significant results. Some treatments that are evidence-based to work for groups may not be helpful to a particular individual, however. It is an imperative that counselors and individuals continually monitor an individual’s condition and progress while engaged in treatment.

I contrast research data – the evidence resulting from research experiments – with “anecdotal data.” I define anecdotal data as an individual’s personal experience. Data from a sample size of one does not provide sufficient information from which a generalization can be made about a group or population. Principles believed to account for outcomes from inspirational individual stories, practitioner wisdom, or theories based on logic, cannot be safely applied to others without first subjecting those principles to rigorous research.

This report may also be of interest:

A Guide for Clinicians to Initial Treatment for Alcohol Use Disorder

Last updated 11/20/18

The views expressed are the author’s alone and do not necessarily reflect the positions of the author’s employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

The Surgeon General’s report, Facing Addiction in America, released in November, 2016, recommends a multi-pronged approach to addiction treatment, in this priority order:

1) medical care, initially from a primary care physician (PCP), to be assessed for a) suitability for medications, b) co-occurring or underlying physical conditions that may be causing stress or distress, including physical pain, and c) co-occurring mental illnesses that may be causing stress, distress, or instability.

2) individual counseling;

3) recovery support services (RSS) to reduce life stressors. Based on clients’ individual preferences, recovery-specific support group attendance may be part of RSS.

Alcohol use disorder (AUD) is defined as a disorder of the organ of the brain which requires medical treatment. Given the nature of the substance, abstinence, rather than harm reduction, is the recommended long-term treatment goal for AUD. Unfortunately, unlike with opioids, no safe dosing of ethyl alcohol exists.

The cognitive functions a person with AUD and other substance use disorders would need for abstention are the very ones impaired by the disorder itself: choice, decision-making, and recognizing the need for change, planning for it, and executing it. The neurobiology of addiction compromises the brain’s basal ganglia, extended amygdala, and prefrontal cortex and, thus, under-sensitizes one to pleasure, over-sensitizes one to pain, automates use of the substance to feel normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
– Nora D. Volkow, M.D, Director of the National Institute on Drug Abuse (NIDA), quoted in What We Take for Granted

Other than with 1) medication and 2) time without exposure of the brain to the substance, brain structures and pathways impaired by AUD currently cannot be directly, immediately and efficiently treated for AUD. Therefore, individuals’ self-care efforts and counselors’ therapeutic efforts will focus on supporting abstinence rather than on attempting to directly treat the brain for addiction.

Alcohol use, even in small amounts, can compromise brain functioning and physical health. In those with alcohol use disorder, physical and behavioral symptoms can be life-threatening to themselves and others. Alcohol withdrawal can be a dangerous, deadly medical condition. Even nurses can be challenged by the symptoms. If a client needs emergency care, call 911. If a client needs urgent care, arrange for it.

The following guide applies to clients who are stable and not in need of urgent or emergency care.

Medical Care

Assist individuals with procuring health insurance and making appointments with medical professionals, beginning with the primary care physician (PHP). If the client does not have health insurance, query community sources for assistance.

(This is normally in the realm of case management rather than traditional clinical sessions, but helping the individual make the phone calls and appointments accommodates possible cognitive impairments associated with use and/or early abstinence. If it’s a personal fit for clinicians, they may consider accompanying individuals to medical appointments.)

Ask non-abstaining clients to keep a log of their consumption of alcohol.

Ask clients to make a rank-ordered list of physical symptoms that cause them stress or distress. (Include physical pain and issues with sleeping and/or eating.)

Ask clients to make a rank-ordered list of mental or psychiatric symptoms that cause them stress or distress.

Help clients compile this data: 1) consumption log (if applicable), 2) physical symptoms, 3) mental or psychiatric symptoms.

Coach clients in advocating for evidence-based treatment when they meet with their PCP. Few PCPs have time to stay up-to-date on the latest in addiction treatment given most work overtime to meet the demand for health care which exceeds capacity. Unfortunately, many PCPs continue to hold the belief that alcoholism is a personal, moral, mental, or criminal problem rather than a medical one.

In the brief appointment clients will have with PCPs, they need to try to make these things happen:

1) Ask to be assessed for medical management of tapering and for medical management of potentially dangerous withdrawal symptoms, including a cost-benefit analysis of the risks of outpatient detox vs. highly stressful and disruptive inpatient detox.

Evidence-based guides to self-tapering from alcohol do not exist. This source, however, may be a place to begin for patient and physician to co-create a tapering plan based on the individual’s alcohol consumption log. Attending rehab is not an evidence-based method for achieving abstinence from substances.

2) Ask to be assessed for medications that assist with abstinence, based on use as recorded in the log. For some patients, naltrexone can be prescribed prior to abstinence, potentially improving progress towards abstinence.. (Here’s an NPR story on naltrexone for AUD.)

3) Ask to be assessed for blood work and for other diagnostic assessments to begin to treat the top items on the list of physical symptoms, or to begin to find the origins of the physical symptoms that are most problematic. Present a copy of the physical symptoms list for reference.

4) Ask for a referral to a psychiatrist now to get on the wait list for an appointment (local wait is 6-12 months). Present a copy of the psychiatric symptoms list for reference.

5) Keep the end in mind, i.e. accomplishing the tasks above, and stay self-regulated if – unfortunately possible – moralistic, judgmental, admonishing, shaming or dismissive statements are made by medical professionals during the appointment, or if follow-up treatment is delayed.

6) Make an appointment now for a follow-up visit with the PCP.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
– Alan Marlatt

Prior to the appointment with the PCP, provide clients with copies of these summary reports on first-line medications for AUD to take with them to offer as reference material if needed:

• Pages 4-24 and 4-25 from Chapter 4 of the Surgeon General’s report, Facing Addiction in America, 2016 ( 2 pages)
• Pages 1-5 of Medication for the Treatment of Alcohol Use Disorder: A Brief Guide, 2012 (6 pages)
• Page containing Abstract (Aims through Conclusions) of “Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders,” 2013 (2 pages)
• Meta-analysis of pharmacotherapy for AUD, 2014 (2 pages)
• Optional, text of article on off-label use of gabapentin (8 pages). (Read more about the off-label use of gabapentin for AUD here, here, and here.)

Fewer than 10% of people with AUD are offered or receive medications to treat the illness. Scientifically sound studies of the comparative efficacy of naltrexone, acamprosate, disulfram and gabapentin do not exist, although one study does compare naltrexone and camprosate. Finding the right medication, or combinations of medications, for each individual takes time.

At risk for premature death from an acute state of AUD, many clients do not have time for trial-and-error experimentation. They may have complicating physical and mental disorders as well. An expert medical opinion, ideally from a physician or psychiatrist, is crucial. We may only have one chance to medically assist a client so we need the most informed, experienced medical advice we can access on the client’s behalf.

Counseling

According to research, individual counseling is more effective than group counseling in helping people with substance use disorders achieve and maintain abstinence. Cognitive behavior therapy (CBT) and related dialectical behavior therapy (DBT), are the therapeutic modalities associated with abstinence. (Here’s a helpful self-directed guide to DBT.) Stress, distress, and exposure to substance-related, environmental cues are the primary precursors for a return to use.

A fundamental skill a person with AUD needs to acquire to increase the likelihood of maintaining abstinence can be termed “self-regulation.” Individuals who can self-regulate emotions, cognitions, attention, as well as moderate ways of relating to self and others, may limit or prevent the escalation of stress or distress to the state of near-dissociation in which a return may occur.

Trained counselors can assist clients with AUD by assisting them with developing self-regulation skills. Therapeutic rapport can help mitigate the stress and distress inherent in therapy and treatment.

In individual counseling sessions, or group sessions if individual sessions are not available, or as a supplement to individual sessions – taking into account cognitive limitations resulting from recent use and/or early abstinence – clinicians can assist clients increase responsiveness (vs. reactivity) to stress and distress, thus to decrease the likelihood of a return to use. Helping clients develop self-regulation requires a shift from focusing on anticipated “people, places and things,” “triggers,” or “choices,” to focusing on using self-regulation in highly unpredictable circumstances, whether with a person, a trigger, or otherwise (see Kaye, et al., 2017).

Since an estimated 70% of people with substance use disorder have experienced trauma, clinicians need to assess for trauma and, if present, given the likelihood of only a few therapy sessions, attempt to provide evidence-based, brief trauma therapy. (Brief interventions are few in number and are still being researched.)

Since approximately half of people with substance use disorder have co-occurring mental illnesses, clinicians need to assess for co-occurring disorders, particularly severe mental illnesses (SMIs) which may qualify clients for additional services.

Since substance use disorder is a 24-7 condition and manifests outside the clinical setting, inform and coach clients on self-care practices that support abstinence.

Recovery Support Services

Query clients about what external factors cause stress and distress in their lives. Ask clients to rank order them, then ask what small improvement would decrease stress or distress in the top three. Take steps to make the improvements happen that are beyond the client’s personal resources or network of connections, or help the client to make them happen.

Assist clients with exploring diverse interest groups, clubs, religious groups, support groups and/or other sources of social connection based on their individual interests and preferences. A sense of belonging, bonding or attachment can be crucial to helping people recover from substance use disorder.

Invite clients to attend support groups. (Choices in the author’s locale for recovery-specific support groups, in order of estimated numbers of attendees per year, are Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery and Celebrate Recovery. Information on local groups is here.)

On a case-by-case basis, support group attendance may be helpful to some individuals with maintaining abstinence. Support group attendance is not, however, an evidence-based treatment for the medical condition of addiction, any more than support group attendance would be treatment for the medical condition of cancer, diabetes, or other dangerous medical conditions.

Connect clients with social services agencies to assist with current stressors and needs such as employment, housing, transportation, child care, and legal issues.

“Love, evidence & respect.”
– Maia Szalavitz, via Twitter, in response to the question, “What fights addiction?”

. . . . .

Given that only one in ten Americans with substance use disorder receives treatment, and the contact a clinician has with a client may be brief, even one-time only, this guide is intentionally brief. It is a work in progress. It is updated as the latest research on AUD is published and the author reviews it.

“Evidence-based treatment” refers to specific treatment protocols that research scientists, through rigorous research methodology, have found work for most people most of the time, better than other treatments, and better than no treatment. Research, by design, reports on groups, not on individuals.

This guide is comprised of evidence-based treatment components, rather than belief-based or theory-based components. This guide, as a whole, has not been tested by research scientists, and therefore it cannot be termed “evidence-based.” It is, however, meticulously researched to include what the latest research reports is most effective. It is intended for informational purposes only and is not a substitute for individualized medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

The intended audience is counselors and clinicians who provide care for people with alcohol use disorders. Individuals and family members investigating current, evidence-informed alcohol use disorder (AUD) treatment may find the content useful as well.

Disclaimer: The views expressed are the author’s alone and do not necessarily reflect the positions of the author’s employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

For further reading:

Outline of an Initial, Evidence-Informed Treatment Plan for Substance Use Disorder

Additional reports on substance use disorder research and treatment by Handshake Media are here.

Last updated 12/21/17

In the U.S., when people think of addiction they usually also think of the 28-day addiction rehab, which was long popularized by the celebrities who used them to try to recover from addiction. As recently as 2013, the magazine People published a compilation of “celebrity success stories” who recovered with the help of traditional rehab.

Yet traditional 28-day rehab, based on the 12-step-heavy, Minnesota Model founded in 1950, is not effective at producing abstinence-based outcomes for people with substance use disorders (SUDs). In fact, scientists have known 28-day rehabs to be ineffective for over three decades. Relapse rates when leaving rehab are as high as 70%, probably higher.

“The position that residential treatment centers and their abstinence-only philosophies are superior to medication ignores overwhelming data and keeps families from seeking the best care. Let’s start with Pinsky’s patients: Nearly 13 percent who appeared on Celebrity Rehab died not long afterward; most had been addicted to opioids.”
– Maia Szalavitz

Facing Addiction in America’s treatment recommendations are, in priority order, medical care, including medications, individual counseling, and support. Further, for some, treatment may not be necessary; spontaneous recovery rates are estimated to occur in 4 to 46% of people with diagnosable SUD.

We delved into the research on rehab and this is what we found:

• Scientists established in the 1980s that treatment for addiction in an inpatient setting is no more effective than in an outpatient setting. Multiple, controlled, randomized studies have shown that when the same treatments are delivered for the same amount of time in inpatient and outpatient settings, no significant differences in outcome are found. (Miller & Hester, 1986; Alterman et al., 1994; Finney, Hahn, & Moos, 1996; Saxe, Dougherty, Esty, & Fine, 1983)
• Inpatient rehabs often cost more than twice the amount of outpatient treatment. (Alterman et al., 1994; Annis, 2008)

“One of [the physicians interviewed] pointed out that you could book a room at a nice hotel for a month (let’s say at $150 per night), have all your meals there ($100 per day), see a psychiatrist twice a week ($300 per visit) and a psychologist three times a week ($275 per visit), get a membership at a fitness club for the month ($100), go to a massage therapist once a week ($100), and you still wouldn’t come out close to the $30,000 that a typical rehab costs for twenty-eight days. If you add it all up, plus throw in seeing an addiction counselor three times a week at a rate of $130 per hour, the grand total for the month comes to not quite $15,000, or about half the price of many a residential rehab.”
– Anne Fletcher (Inside Rehab 98)

• People treated in outpatient programs are less likely to return to hospital or inpatient care, which further reduces costs of treatment over time. (Annis, 2008)

“Day clinic patients showed significantly fewer hospital readmissions and fewer days hospitalized during the one year follow-up period; this finding agrees with a growing body of evidence in the mental health field indicating that alternatives to inpatient programming foster lower subsequent rates of utilization of hospital beds.”
– Helen M. Annis, Ph.D. (1985)

• Most of the revenue (about 80%) for specialty addiction programs, including inpatient rehabs, comes from taxpayer-funded, government sources. (Kimberly & McLellan, 2006)
• Once the dominant form of addiction treatment, the 28-day rehab is no longer well-supported by insurers. Most people who receive treatment for addiction are treated on an outpatient basis. (Inside Rehab 16)

“After numerous studies showed no difference in how people fared after going to residential versus outpatient programs, insurers and other funding sources drastically cut back on paying for residential rehab. Today, various forms of outpatient help comprise more addiction treatment experiences in the United States than residential stays.”
– Anne Fletcher (Inside Rehab 16)

“Of the types of care offered at these programs, 81 percent were outpatient, accounting for nine out of ten of all clients in treatment. About a quarter of the programs offered residential (nonhospital) treatment, which accounted for about one out of ten clients in rehab.”
– Anne Fletcher (Inside Rehab 22)

• However, specialty programs (inpatient and outpatient) focused exclusively on addictions treatment, still comprise about 80% of the nation’s addiction treatment programs. The addiction treatment system is not well-integrated with the rest of medicine. (Kimberly & McLellan, 2006)
• New science has shown that addiction is a chronic condition, requiring years of treatment.

“The idea that someone goes away to a thirty-day rehab and comes home a new person is naïve. Rather, there’s a growing view that people with serious substance use disorders commonly require care for months or even years, just as they would for other chronic medical conditions, such as diabetes.”
– Anne Fletcher (Inside Rehab 16-17)

• Most rehabs in the United States rely heavily or entirely upon 12-step approaches for their curricula, which is not evidence-based as treatment for addiction. (Szalavitz, 2016; Sindewald, 2017)

“When I wrote Sober for Good, more than 90 percent of rehabs in the United States were based on the twelve steps. While the ratio appears to have dropped somewhat, most programs still base their approach on the twelve steps, include a twelve-step component, require twelve-step meeting attendance, and/or hold twelve-step meetings on-site.”
– Anne Fletcher (Inside Rehab 18)

• The first inpatient rehab for addiction, Hazelden, which was responsible for creating the “Minnesota Model” of addiction treatment later adopted almost universally by United States rehabs, was founded by members of Alcoholics Anonymous. Alcoholics Anonymous is a religious self-help group founded by non-professionals in 1935, and is most known for the 12 Steps. (Anderson, McGovern, & DuPont, 1999; Wikipedia)
• Inpatient rehab programs rely heavily on group counseling, which is not effective as a treatment for addiction. (Surgeon General’s Report, 2016)

“While group counseling is the staple approach in the vast majority of programs, there’s little evidence that the type of group counseling used at most of them is the best way to treat addictions.”
– Anne Fletcher (Inside Rehab 17)

“…if a client is a ‘group’ person, traditional residential rehab probably will agree with him or her; if not, too bad, because there’s some type of group counseling, education, lecture, or other group activity about eight hours a day–not including meals.”
– Anne Fletcher (Inside Rehab 83)

• Some rehabs, particularly those with heavy 12-step emphasis, do not think people with addiction should be treated with drugs. (Szalavitz, 2016)

“Research clearly shows that certain prescription medications help people addicted to drugs and alcohol get sober and stay sober. yet many rehabs are unfamiliar with them or refuse to use them because of the old-fashioned notion that drugs should not be used to treat an addict–or that they should be used very sparingly.”
– Anne Fletcher (Inside Rehab 21)

• Of inpatient rehabs, 54% do not have physicians or psychiatrists on-staff who could prescribe the medications evidence-based for treating addiction, and less than 25% have licensed social workers or counselors on staff to provide evidence-based behavioral therapies. (Kimberly & McLellan, 2006; Knudsen, Roman, & Oser, 2010)

“In many states, anyone can open a rehab program — no licenses or accreditation are required.”
– David Sheff

• Science has developed new treatments for addiction, but rehabs have been slow to adopt new methods and pharmaceutical treatments. (Miller et al., 2006)

“…people with alcohol addiction receive care ‘consistent with scientific knowledge’ only about 10 percent of the time.”
– Anne Fletcher (Inside Rehab 29)

When we looked at what the Surgeon General’s Report, Facing Addiction in America, had to say about inpatient treatment, we were surprised, after our research, to see that the report included residential (28-day rehab and similar services) and inpatient (hospital settings) services as evidence-based treatment for addiction.

“Residential services offer organized services, also in a 24-hour setting but outside of a hospital. These programs typically provide support, structure, and an array of evidence-based clinical services. Such programs are appropriate for physically and emotionally stabilized individuals who may not have a living situation that supports recovery, may have a history of relapse, or have co-occurring physical and/ or mental illnesses.” –Facing Addiction in America

• In a study of 151,983 patients in England with opioid dependence, successful completion of treatment, including residential rehab, was not associated with a reduction in risk of fatal drug-related poisoning. (Pierce et. al, 2015)

We were unsuccessful in finding research studies demonstrating the efficacy of rehab for abstinence-based outcomes for people with substance use disorders.

Traditional, residential rehab programs are infamous for misrepresenting their treatments’ success rates, and for not following up with clients to determine long-term outcomes. Much of what we did find concerned inpatient (residential and hospital lumped together) vs. outpatient treatment settings. Our research unequivocally showed that the two settings yield comparable results, but that treatment on an outpatient basis is much more cost-effective.

Where does that leave us with regard to evaluating the efficacy of rehab? Right now, we don’t know.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

More reports from Handshake Media are here.

This information sheet links to primary sources, secondary sources that report on multiple primary sources, informed commentary, and reports from our own literature reviews. To aid in creating printable copies with sources, we have primarily posted the link rather than linked the text.

• Opioid Use Disorder (OUD) is a chronic condition requiring long-term care.
  Source: http://www.sciencedirect.com/science/article/pii/S0955395916302985
• Of pain patients who are prescribed opioids, about 8% develop opioid use disorders. Most people with opioid use disorders began by using opioids obtained from a friend or family member.
  Sources: http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
  https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/
  http://www.pbs.org/newshour/rundown/opioid-misuse-starts-friend-family-members-prescription/
• An estimated 80% of people who try abstinence-based behavioral treatment or detoxification relapse.
  Source: http://www.tandfonline.com/doi/abs/10.1080/10550887.2012.694598
• Individual counseling and group counseling, by themselves, are not evidence-based treatments for opioid use disorder. Individuals receiving only counseling are at higher risk of death than individuals on opioid maintenance treatment.
  Sources: http://www.handshakemediainc.com/2017/02/05/on-counseling-and-medication-assisted-treatment/
  http://onlinelibrary.wiley.com/doi/10.1111/add.13193/full
• People are more likely to fatally overdose prior to beginning maintenance medication and upon ceasing it than are those with continuous treatment.
  Sources: http://www.bmj.com/content/357/bmj.j1550
  http://www.sciencedirect.com/science/article/pii/S0740547216304123
  https://www.ncbi.nlm.nih.gov/pubmed/20978062
• Only buprenorphine or methadone maintenance treatments are known to cut death rates by half or more.
  Sources: https://www.ncbi.nlm.nih.gov/pubmed/20978062
  https://www.ncbi.nlm.nih.gov/pubmed/25601365
• While oral naltrexone, and extended-release naltrexone marketed as Vivitrol, may be helpful to some, only buprenorphine and methadone are supported by the data in terms of reducing death rates. Further, naltrexone is associated with depression in some individuals, and the risk of overdose and death is high upon cessation of naltrexone. Overdose is eight times higher, and the death rate is four times higher, in people with OUD who stop taking naltrexone vs. those who stop taking buprenorphine or methadone. Naltrexone can block a sense of social connection, considered fundamental to recovery from addiction. Extended-release naltrexone is more expensive than buprenorphine and methadone, making it a fiscally unsound choice for publicly-funded treatment given its lack of evidential support. The company that manufactures Vivitrol, Alkermes, is marketing the drug directly to court judges and other criminal justice officials. Despite the weak evidence base for Vivitrol, judges in drug courts are now mandating Vivitrol, essentially prescribing without a medical license.
  Sources: https://fivethirtyeight.com/features/what-science-says-to-do-if-your-loved-one-has-an-opioid-addiction/
  http://onlinelibrary.wiley.com/doi/10.1111/dar.12205/full
  https://www.vice.com/en_us/article/7x9ypq/how-safe-is-americas-hottest-heroin-addiction-treatment
  https://www.statnews.com/2017/06/29/vivitrol-methadone-opioids/
  https://www.ncbi.nlm.nih.gov/pubmed/28274648
  http://www.npr.org/sections/health-shots/2017/08/03/540029500/to-grow-market-share-a-drugmaker-pitches-its-product-to-judges

“In the United States, a monthly injectable form of long-acting naltrexone (Vivitrol) was approved in 2010 as a third medication option for opioid addiction treatment. In the United States, opioid substitution therapy and extended release naltrexone are grouped together in the category ‘medication assisted treatment’ (MAT), to distinguish these treatments from abstinence only methods. Less than half a dozen trials of long-acting naltrexone have been published and they show promising results in terms of reducing relapse. There is little long-term data, however, and extended-release naltrexone has not been shown to reduce mortality or disease. It may even increase overdose death risk upon cessation. Vivitrol is not approved in Canada, although it is available under the country’s special access program in reaction to the opioid crisis.”

– The Opioid Crisis in North America, Global Commission on Drug Policy, October, 2017

• Maintenance treatment reduces rates of disease.
  Source: http://onlinelibrary.wiley.com/doi/10.1111/add.12682/full
• For those with OUD who are part of the criminal justice population, maintenance is known to reduce rates of re-incarceration by 20% or more.
  Sources: http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03618.x/full
  http://www.tandfonline.com/doi/abs/10.3109/16066359909004372
  https://www.drugabuse.gov/publications/principles-drug-abuse-treatment-criminal-justice-populations/principles
• A minimum of 12 months is recommended for maintenance to be effective.
  Source: https://www.ncbi.nlm.nih.gov/pubmed/20978062
• People must be in remission from illicit opioid use for at least five years before risk of relapse decreases substantially.
  Source: http://journals.lww.com/hrpjournal/Abstract/2015/03000/Long_Term_Course_of_Opioid_Addiction.3.aspx
• Many individuals need long periods of maintenance on methadone or buprenorphine before they are stable in remission, even 17 years or longer, sometimes lifelong.
  Sources: http://www.sciencedirect.com/science/article/pii/S0376871616308675
  https://www.karger.com/Article/PDF/468518
  http://www.sciencedirect.com/science/article/pii/S0376871617301977

A shortened, printable .pdf of the information sheet is here.

A printable .pdf of the infographic by Laurel Sindewald is here. It is updated from our original post here.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Related reports on addictions treatment, addictions recovery, and addictions policy from Handshake Media, Incorporated:

• On Counseling and Medication-Assisted Treatment, February 5, 2017
• Why Opioid Maintenance Does Not Replace One Addiction with Another, October 21, 2016
• Addiction or Dependence: A Life and Death Difference, October 18, 2016
• Understanding Why We Have Wait Lists for Opioid Addictions Treatment, June 2, 2016
• What the Opioid Epidemic Means in Virginia, March 4, 2016

This post was last updated 10/31/17.

Complex and interacting factors can predispose people to developing addiction, defined by the National Institute on Drug Abuse as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” Genetics, psychology, psychiatry, and sociology are contributing to a more complicated understanding of how and why addiction develops in 1 in 7 people, or about 14%.

Genetics and Epigenetics

Genetics is well-known as the field that studies DNA, or the amino acid code that serves as a blueprint for living creatures. Epigenetics, being a newer sub-field of genetics, is rather less well-known. Epigenetics is a field examining the chemical compounds and proteins that attach to DNA, and influence how and whether the DNA is translated. For example, certain proteins can turn genes on or off, or modify how much protein is made from (i.e. translated from) a gene. Epigenetic changes often happen due to environmental influences throughout a person’s life, and are heritable.

An estimated 40-60% of addiction risk is genetic, but researchers don’t know yet which specific genes are at the root of the risk. This is in part because, in the case of addiction, each suspected gene has a very small influence, but all the genes together seem to have a very large influence. To identify all of the small influences of the individual genes would require experiments with very large sample sizes.

The question of which genetic factors predispose people to developing addiction is further complicated by epigenetics, such that a person’s risk may be increased or decreased depending on his or her environment. The drug itself, social interaction, or stressful life events can all alter a person’s epigenetics so that the person is at higher risk for addiction. Because of these interactions between genetics and environment, so far it is impossible to say exactly how much of addiction is due to nature (genetics/inherited epigenetics) and how much to nurture (environment/experiences). It is safe to say that people are or become predisposed to developing addiction, probably due to both genetic and epigenetic variables.

Mental Illnesses and Personality Disorders

People with addiction can have co-occurring mental illnesses and personality disorders, for which they may have been self-medicating when they developed addiction. Some of the genetic risk for addiction may be indirect, via a genetic risk for other disorders.

“In fact, the majority of genetic influence on substance use outcomes appears to be through a general predisposition that broadly influences a variety of externalizing disorders and is likely related to behavioral undercontrol and impulsivity, which is a heterogeneous construct in itself.”
– Dick 2016

One study found that 28% of people with alcohol use disorders (AUDs) and 47.7% of people with drug use disorders had at least one personality disorder. Specifically, 18% of people with substance use disorders (SUDs) overall (including AUDs) have antisocial personality disorder, a rate more than four times that of the general population, which may be the source of the myth of the “addictive personality.”

Disorders that are commonly comorbid with addiction include:

• Anxiety and mood disorders
• Schizophrenia
• Bipolar disorder
• Major depressive disorder
• Conduct disorders
• Post-traumatic stress disorder (PTSD)
• Attention deficit hyperactivity disorder
• Antisocial personality disorder

When these disorders precede the development of addiction, they are said to be precursors, and may contribute to overall addiction risk. We cannot say yet, however, whether any of these precursors have definitive, causal influence in the development of addiction.

Trauma

PTSD is one of the disorders most commonly comorbid with addiction, and warrants special emphasis. The relationship between trauma and addiction is very strong, and trauma is suspected to be a causal influence in the development of addiction. An estimated 66% of people with SUDs have experienced trauma, and about half have PTSD.

Trauma may include emotional, sexual, or physical abuse, and is especially damaging for children. Adverse childhood experiences (ACEs) are known to increase addiction risk, with children who have experienced 5 or more ACEs 7 to 10 times more likely to develop addiction. Even one ACE before the age of 15 doubles a child’s risk of addiction, based on a study of the population of Sweden. People who develop PTSD or experience trauma symptoms following community violence are also known to be at elevated risk for developing addiction.

Personality and Temperament

While there is no one addictive personality, certain personality and temperament traits are associated with higher rates of addiction.

“Yes, some stand out because they are antisocial and callous – but others stand out because they are overly moralistic and sensitive. While those who are the most impulsive and eager to try new things are at highest risk, the odds of addiction are also elevated in those who are compulsive and fear novelty. It is extremes of personality and temperament – some of which are associated with talents, not deficits – that elevates risk. Giftedness and high IQ, for instance, are linked with higher rates of illegal drug use than having average intelligence.”
– Maia Szalavitz

Some of these personality traits may be or become severe enough to be diagnosable as a personality disorder, but in other cases a person may simply be prone to feeling anxious or hopeless, or being impulsive or sensation-seeking. These traits would also be accurately described as being precursors to addiction, possibly increasing addiction risk.

Attachment Security

Attachment theory has been studied for decades, beginning with research on infant-parent relationships, and expanding to research on adult relationships.

“Attachment theory examines the quality of infant relationships with their caregivers, and correlates these relationships with the quality of relationships people have later in life. Basically, the more securely an infant bonds with a caregiver, the more secure that infant will feel in other relationships later in life.”
– Addiction Recovery with Others is Easier than Recovery Alone

Some theorize that addiction is an attachment disorder. Dr. Philip Flores is the founder of this idea, arguing that people with poor attachment are suffering from emotion regulation difficulties, and are essentially unable to regulate their self-esteem and relationships without healthy attachment. He posits that people suffering from insecure attachment use substance or behaviors to substitute for healthy relationships, which seem at first to help but ultimately exacerbate their problems.

We do not know whether Dr. Flores is correct, but we do know that insecure attachment styles are associated with addiction and with poor emotion regulation, as well as with other mental illnesses. Insecure attachment may therefore be considered to be another precursor to the development of addiction, in close association with the risk factors of co-occurring mental disorders.

Recently, researchers are exploring whether oxytocin (the neuropeptide and hormone thought to be responsible for social bonding) and social attachment may protect against addiction and stress. The neurological systems for stress coping and for social attachment overlap, and these researchers hypothesize that oxytocin is responsible for the transition people experience from wanting/searching for social attachment to liking/loving a person.

“The authors suggest that through dopaminergic, serotonergic and endogenous opioid mechanisms, oxytocin is involved in shifting the balance between wanting and liking in corticostriatal loops by facilitating consolidation of social information from ventral reactive reward systems to dorsal internal working models that aid in prospectively selecting optimal actions in the future, increasing resilience in the face of stress and addiction.”
–Tops et al., 2014

Essentially, Tops et al. suspect that the process of developing familiarity and liking for other people, with the help of oxytocin, helps people to cope with stress, and makes them more resilient and less likely to become addicted.

Socioeconomic Influences

Poverty is a source of chronic stress, which may increase a person’s risk for mental illnesses. Fatal opioid overdose rates and emergency room visits are strongly correlated with unemployment rates, increasing 3.6% and 7% respectively for each 1% increase in unemployment. People in poverty are more likely to become addicted, in part because people in poverty are more likely overall to develop mental illnesses. Furthermore, mental illnesses may make it harder for a person to gain or keep employment and/or housing, which could lead to further or worsening poverty.

“Growing international evidence shows that mental ill health and poverty interact in a negative cycle in low-income and middle-income countries.”
–Lund et al., 2011

Poverty is also known to have intergenerational influences, with chronic stress and poverty having epigenetic (therefore heritable) impacts on, for example, a person’s ability to cope with stress.

Other social-environmental influences may put someone at increased risk for addiction. For example, being surrounded by many people who use drugs tends to increase a person’s risk of developing an SUD, because the drugs are more available and people are more likely to use together more often. Furthermore, drug use in the home may result in more stressful situations, including poverty, that in turn put other people in the home at higher risk for addiction or other mental illnesses. Especially in cases of social isolation and poverty, such as in some rural areas of America, almost everyone in a community may develop addiction (e.g., the recent opioid epidemic).

Physiological Influences

Some people metabolize alcohol differently than others, and so are at higher risk for addiction. Some people are at heightened risk because of sleep disturbances or poor sleep quality. Others are at risk because of physical pain. People with physical disabilities, and/or traumatic brain injuries, are also known to be at higher risk for addiction. Women and men are equally likely to develop addiction, but sex, gender, race and ethnicity may influence the course addiction takes.

Developmental Stage

Adolescents are at higher risk for developing addiction, though many end up “aging out,” and recover on their own once their brains have developed. Human development is highly influenced by social environment, as well as genetics. If many of the above risk factors coincide with adolescence, a person is more likely to develop addiction.

Because of extreme variability in the precursors and predisposing conditions influencing the development of addiction, we may never have a one-size-fits-all treatment solution. By understanding all of the complex and interacting variables that predispose people to addiction, however, we can begin to determine which people are at highest risk, identify risks that we can mitigate, and create individualized treatment plans to ameliorate addiction, co-occurring mental and physical disorders, and life stressors.

Photo: Detail of collage, Mary Wilson Burnette Giles, 1963

This post was last updated 5/4/17.

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