In its 1990 report on the treatment of alcohol problems, the
Institute of Medicine provided a definition of treatment that applies to
treatment of other substance abuse as well and that takes into account the
continuum of care, from outreach (identification) to continuing care:
Treatment refers to a broad range of services, including
identification, brief intervention, assessment, diagnosis, counseling, medical
services, psychiatric services, psychological services, social services, and
follow-up, for persons with alcohol problems.'
The need for an array of comprehensive services much more extensive than one
that merely focuses on alcohol and other drug use has been also underscored in
CSAT's Comprehensive Treatment Model for Alcohol and Other Drug Abusing Women
and their Children, which describes the types of medical, psychological, and
social services that should constitute the full range of treatment for women
and their children (presented in appendix A; the categories of services
recommended in the comprehensive model are described in section 3.4.1). As the
model states, "Treatment that addresses alcohol and other drug abuse only
may well fail and contribute to a higher potential for relapse."2
Treatment programs must not only offer a continuum of services both internal
and external, from outreach through follow-up and continuing care-they must
integrate these services within the larger community. Because many factors
affect a woman's substance abuse problem, the purpose of comprehensive
treatment, according to the CSAT model, is to "address a woman's substance
abuse in the context of her health and her relationship with her children and
other family members, the community, and society."' An understanding of
the interrelationships among the woman/client, the treatment program, and the
community is critical to the success of the comprehensive treatment approach.
The intent is to consider the holistic needs of women-an adaptation of the
World HealthOrganization's
definition of health as well-being rather than an absence of
disease. As CSAT notes in its statement of mission, goals, and programs:
The general consensus among those foremost in the field of addic
tion is that, for most individuals, treatment and recovery services
work best in the context of a community-centered, coordinated
system of comprehensive services designed to assure a continuum
of support for recovery.'
Thus, the comprehensive treatment model makes clear that caring for
women with substance
abuse problems must be part of a broad public
health and social services response. The interrelationships between a
treatment program offering comprehensive services for women and the
community are depicted in Figure 1 (see page 70). This model depicts the
broad public various aspects of the community which impact on the client and
with
which she may interact in the process of initiating alcohol or other drug
use, continuing its use, and engaging in and continuing the recovery pro
cess. These include, for example, the availability of illicit drugs in her
community, local laws and practices that govern distribution of alcohol, the
local economy and related unemployment rates (which impact on her
ability to obtain gainful employment), and the availability of health and
social services prior to, during, and following treatment. Within the con
text of the treatment program are the various phases of care with which the
client interacts and which are related in turn to the myriad of community
variables. For example, the degree to which the treatment program can
provide comprehensive services is in part dependent on the availability of
social and other support services in the community (e.g., primary health
care, low-income housing) as well as on the ability of the program to
formulate and maintain community linkages. This model thus describes the
interdependence of the client, the treatment program, and the broader
community in which they exist.
3.1 CSAT's Vision of Treatment
From CSAT's
perspective-and from the perspective of many in the field of addiction
treatment-the goals of treatment service and recovery programs should be the
following:
attract and retain individuals in treatment and recovery; reduce
alcohol and other drug use by these individuals; reduce rates of relapse by
these individuals;
improve the individual's physical health and psychological
wellness; and - improve family, social, and economic functioning.
Infectious Rural or Urban
Disease Rates Population
Treatment and Economics Planning
Political
Treatment of Alcohol and Other Brug Abuse: An Introduction 71
sive services
required can vary according to the gender, race, ethnicity, socioeconomic
status, age, and physiological and neurophysiological condition of the client.
This chapter also presents a condensed discussion of key issues related to
women in recovery, as well as issues that apply to all stages of care.
3.2.1 Treatment
Methods
Generally, treatment
of substance abuse includes the following methods:
· pharmacological treatment, including, for example:
- the use of antabuse in the treatment of alcoholism.
Antabuse is an alcohol-sensitizing drug used primarily
during the initial course of treatment and rehabilitation; and
- the use of methadone in the treatment of heroin addiction.
Although originally developed for use in detoxification of
heroin addicts, methadone is now used primarily as a
maintenance drug for indefinite periods;
(Please note: Although it is not commonly used, naltrexone has
been an adjunct in the treatment of opioid addiction. Data does not support its
effectiveness.)
· psychosocial treatment, including biofeedback and role playing;
psychological counseling that involves the client and her family/ significant
others;
· nontraditional healing (e.g., acupuncture); and
· social learning, which usually requires becoming and remaining
drug-free and which focuses on the social service needs of the client.
These methods of care are
not mutually exclusive. In fact, they are often used in combination or
sequentially at different stages in the treatment process. For example, many
programs combine psychosocial treatment with social learning and/or
nontraditional healing methods. Methadone treatment usually includes
rehabilitative counseling, psychotherapeutic services, and comprehensive
medical services.
Increasingly, as treatment of substance abuse is linked with programs that
provide services to persons with AIDS or who are HIV-positive, persons in the
field are struggling to determine the most appropriate combination of care
modalities to serve these clients. The CSAT Comprehensive Treatment Model
suggests that, at a minimum, the [treatment] program must provide for pre- and
post-test counseling for clients seeking to be tested for HIV. Individual
counseling and support groups should be provided for clients diagnosed with HIV
or AIDS. Staff should be properly trained to intervene on' behalf of those who
are HIV-seropositive, whether symptomatic or asymptomatic.
3.2.2 Modalities
of Care
Modalities of substance
abuse treatment can be classified in many ways. Among these are: by setting
(e.g., inpatient/medical facility-based, residential, or outpatient); by length
of care (e.g., short-term or long-term); and by philosophical approach (e.g.,
medical model or social services model).
The remainder of this chapter summarizes the services provided in the most
frequently used types of modalities based on the setting of care: inpatient
detoxification, residential treatment and rehabilitation, outpatient
detoxification, and outpatient treatment. Generally, these classifications
apply for treatment programs that address problems of substance abuse or a
combination of alcohol and other drug use. In reality, treatment is not
usually static, but
often occurs in different settings and with the use of different treatment
modalities. Most commonly, there is a continuum of services from the following:
· inpatient detoxification, referral to residential treatment and
rehabilitation, referral to outpatient or intensive day treatment, and
continuing care and follow-up, or
· residential treatment and rehabilitation referral to outpatient
rehabilitation, and continuing care and follow-up.
Inpatient or residential detoxification, whatever the setting or
approach, is designed to facilitate the client's safe physiological withdrawal
from drugs. Services usually include intensive client counseling to encourage
further treatment and referral of detoxified persons to appropriate treatment
programs for continuing care. Detoxification programs can last from one to
seven days. However, they may be longer for women withdrawing from addictive
prescription drugs, for pregnant women, for women who present with medical
risks, or for those who have co-occurring disorders, including for example,
mental health disorders, eating disorders, and other health problems.
Inpatient detoxification services can include the following: nursing care;
individual, group, and family counseling; physical examinations (including
laboratory tests); psychiatric evaluations; the provision of medications (for
social setting programs, these would be limited to medications for other health
problems); education concerning alcohol and other drugs; and referral for
longer term treatment. Inpatient detoxification, which focuses on medical
stabilization, is provided in two types of settings:
· short-term inpatient services provided in a medical facility
(e.g., a hospital) or in a non-hospital residential facility that has medical
services available. In these settings, the goal is to reduce
systematically the amount of alcohol or other drugs in the body
through medications given by medical personnel under a physician's supervision.
· short-term services provided in a residential setting by trained
personnel, with physician services available when required. Such facilities
(which are often considered to provide "social detoxification") can
include freestanding inpatient treatment centers, quarterway houses, and
halfway houses.
Residential treatment and rehabilitation are provided to
individuals who need treatment services in a controlled and structured
environment over a longer period of time.
Many clients are referred to residential treatment programs because they are
experiencing withdrawal symptoms, psychotic manifestations, or severe illness
related to substance abuse. In the latter case, they are usually stabilized in
a medical facility before entering the residential program for treatment.
Others are referred (or refer themselves) because the counselor or the client
believe that the structured setting will benefit the . client. Sometimes
hospital-based residential programs are the only treatment resource available
or the only one that is covered by the client's third-party payer (public or
private). As with inpatient detoxification, two types of settings predominate:
· services provided in a medical facility or in a non-hospital
residential program that, if affiliated with a medical facility, have medical
services available and that may use medication as a means of treatment (e.g.,
methadone for treatment of heroin addiction), and
· services provided in a residential setting by trained personnel,
with physician services available when required.
Residential treatment and rehabilitation services can be short-term (seven to
60 days, depending on the type of facility) and longer term (30
