Support and Advance Effective Treatment

Introductory Paragraph

According to a 2022 national survey, about 48.7 million people ages 12 and over in the United States had a substance use disorder within the past year. Only about 11% receive treatment. SUD is a substantial problem for Americans, with nearly 20 million reporting having a substance use problem. This is alarming, as the effects of a SUD extend well beyond the individual, impacting families, communities and the economy in a significantly negative way. The social stigma surrounding alcohol and substance use has made access to treatment less equitable and less attainable. Despite evidence-based, successful methods for treatment and recovery, barriers are ever-present and include a severe professional shortage, high costs, social stigma, and fear of retaliation. . Creating social awareness of the benefits of treating and supporting those with a SUD is essential to breaking down barriers and improving access. There is an increasingly important need to provide options for individuals who may benefit from quality and affordable alcohol and drug treatment programs. The demand for treatment is met with a shortage of quality recovery centers in America, which makes it difficult for individuals and their families to receive the care they need. The small populations in rural communities, for example, cannot support the specialized treatment or trained primary care practitioners who are willing to treat individuals living with addiction. This leads many individuals to either go without care or join waitlists for treatment.

Those living with substance use disorders are among the highest cost of healthcare users. Overdose patients in particular place a heavy burden on first responders, emergency departments, and the foster care system. Some options to solve this issue could include innovations such as expanded use of online tools and assessments, integration of primary care treatment, and virtual reality.

There are several evidence-based therapies for alcohol and drug misuse, with most common being talk therapy, medications, and support groups. Evidence-based therapies include cognitive behavioral therapy and 12 step-programs. Medication-assisted treatment has also proven effective in treatment of opioid use disorder. Medication in combination with talk therapy can reduce withdrawal symptoms and promote long-term recovery.

Key Information

There are multiple effective pathways leading to long-term recovery and improvements in work, family, relationships, and overall mental health and well-being. Substance use disorders treatments which meet the needs of the individual may include the following:

• Therapy (individual, group, couples & families)
• Medications
• A combination of therapy and medications
• Peer support programs
• 12-step or recovery programs
• Family support and family recovery programs

Treatment Options

There are inpatient treatment choices, such as residential treatment, and outpatient options, depending on what is best suited for the level of care for an individual. Treatment may require detox on either an outpatient or inpatient basis, depending upon professional medical advice. Other treatment programs include recovery coaching, recovery housing, recovery management, peer-led recovery community centers, and recovery-based education. Specific evidence-based treatments that have been researched and scientifically proven include:

• Cognitive behavioral therapy (CBT) provides one-to-one attention by a a therapist. CBT has been proven to reduce substance use and to have a positive impact for life improvements. CBT has also been proven to be effective with trauma which often coincides with substance use disorders.

• 12-step therapy programs, such as Alcoholics Anonymous and Narcotics Anonymous, are self-help group programs which are evidence-based in assisting with maintaining sobriety. While quite common, there is some controversy associated with an emphasis on total abstinence, which limits advancing multiple pathways. Likewise, the documentary "The Business of Recovery" maintains that 12-step programs are typically only helpful for 5-10% of people who partake in them.

• Medication-assisted treatment (MAT) is available in accredited and certified private and public clinics across the United States. It is a combination of medications and talk therapy. Depending on the substance, MAT is an evidence-based option for recovery from alcohol and opioid use. MAT A combination of medication, counseling, and behavioral therapy is regarded as the most effective in treating opioid dependency. The Substance Abuse and Mental Health Administration (SAMHSA) is responsible for overseeing the certification of opioid treatment programs which use Buprenorphine, Methadone, and Naltrexone.

Implementing Treatment in the Primary Care Setting

Primary care providers are highly likely to come in contact with individuals who are struggling with substance use disorders, but only about 3,600 physicians are board-certified in treating addiction. Approximately 4% of all physicians nationwide are certified to prescribe medication for opioid use disorder. A majority of individuals who use MAT must obtain their medication from Methadone clinics. While these clinics are helpful in assisting people in getting their medication, it is difficult for specialty clinics to meet the demand for services. This calls for more primary care providers to obtain the training and certifications to treat complex cases of substance use disorders. One possible solution for getting more primary care physicians to assist in this issue is to incentivize the screening and treatment of addiction. There are many challenges that primary care providers may face when choosing to treat addiction patients, including stigma, the complexity of this population, and reimbursement for services.

Relevant Research

HHS has a report titled "Best Practices and Barriers to Engaging People with Substance Use Disorders in Treatment." This study addresses the models of care, quality improvement interventions, and best practices used by higher-performing health plans to improve initiation and engagement in SUD treatment. It also describes the provider, beneficiary, and market factors that affect their ability to successfully initiate and engage beneficiaries in substance use treatment services.

This NIDA article provides a literature review of treatment communities, such as community lodges and sober houses that have seen themselves as a mutual self-help alternative to medically oriented strategies to address addiction.

This book is in its third edition and is titled "Principles of Drug Addiction Treatment: A Research-Based Guide." It offers health professionals and other stakeholders information on principles of effective drug addiction treatment, answers to frequently asked questions, an overview of the drug addiction treatment landscape in the United States, and an outline of evidence-based treatment approaches.

This book provides a set of analyses focused on the evaluation of alcohol and drug treatment programs.

This article provides a comprehensive review of empirical studies that have addressed differences in patient outcomes and retention rates and their correlation to the effectiveness of the therapists. It notes that the differences appear to be independent of both the therapists' professional background and the patient factors at the start of therapy and that the primary therapist characteristic associated with higher effectiveness is the possession of strong interpersonal skills.

This article provides a review and meta-analysis of treatment services for patients with alcohol use disorders. The research found that pharmaceutical interventions when used with psychosocial co-interventions, resulted in better outcomes. This supports the advantage of the strategy of adding medication to treatment programs for opioid users.

Cost/Benefit Analysis. Drug treatment programs are known for being expensive and difficult to find. Current research suggests that when people are able to enroll in treatment, the benefits impact not only on individuals living with a substance use disorder but also healthcare administrations, law enforcement, and the criminal justice system. Recent data suggests that every dollar spent on substance use treatment centers saves $4 in health care costs and $7 in criminal justice and law enforcement involvement. Over $8,200 can be saved on health care and productivity costs per individual who spends at least 60 days in a quality substance abuse treatment program. Thus, it is effective to invest taxpayer dollars and government resources to implement accessible, affordable, and quality treatment centers -- regardless of access to insurance or financial status.

This article reports on research which found that lack of patient motivation for treatment significantly impacts retention and successful outcomes, implying that increasing patient motivation is critical prior to and during treatment programs.

This chapter within the book, "Women, Children, and Addiction," addresses the importance of gender issues in substance use research and emphasizes the importance of gender-sensitive treatment and approaches.

Impactful Federal, State, and Local Policies

The STOP Act. The Sober Truth on Preventing (STOP) Underage Drinking Act of 2006 which was reauthorized in 2016 as part of the 21st Century Cures Act. It mandates community coalition enhancement grants, epidemiological research on excessive and underage drinking, and the annual report to Congress on state underage drinking and enforcement activities. It also launched a national adult-oriented media campaign managed by the Interagency Coordinating Committee to Prevent Underage Drinking (ICCPUD).

Facing Addiction in America: The Surgeon General's Report provides a review of prevention, treatment, and recovery policies and programs and discusses opportunities to bring substance use disorder treatment and mainstream health care systems into alignment.

California. The Safe Neighborhoods and Schools Act (Proposition 47) reclassified certain theft and drug charges from felonies to misdemeanors enabling focus on more violent crimes and serious offenses. This resulted in monetary savings being directed to school programs, victim services, and mental health. The creation of new drug treatment programs offered a way to decrease recidivism and to support those with newly classified misdemeanor drug possession charges to have more options for recovery.

Available Tools and Resources

SAMHSA has numerous resources including:

• Behavioral Health Treatment Services Locator -- a confidential and anonymous source of information for persons seeking treatment facilities for substance use/addiction and/or mental health problems. FindTreatment.gov allows users to search for treatment centers while filtering for treatment type, location, and payment options to include private health insurance, Medicaid, or free or no-cost care. There are also filters for special populations such as veterans, LGBTQ+, differently abled individuals, age groups, and language preference.
• The Evidence-Based Practices Resource Center which provides communities, clinicians, policy-makers, and others with information and tools to incorporate evidence-based practices into their communities or clinical settings.
• "Selecting Best-fit Programs and Practices: Guidance for Substance Misuse Prevention Practitioners." This resource places the selection of programs and practices within the broader context of evidence-based prevention and covers the value of embedding program and practice selection in a strategic planning process. It provides information on programs and practices, how to choose among them, and tips for their adoption, adaptation, and implementation, and continual improvement.

SAFE Project:

• Treatment and Family Support Locator is a SAFE Project and University of Maryland created resource designed to allow users seeking substance use/mental health treatment to search the SAMHSA Treatment Locator database using more specific criteria to help find the best options available.
• "SAFE Community Playbook" is a downloadable resource that provides a blueprint on how communities can convene a local coalition, conduct an assessment, and prioritize actions to address the addiction epidemic.

BJA has published "Promising Practices Guidelines for Residential Substance Abuse Treatment." This aims to assist correctional administrators and practitioners at the state and county levels in establishing and maintaining programs that adhere to the promising practices suggested by current research and standards for substance-use disorder treatment and criminal justice programming.

The National Association of Addiction Treatment Providers has a web page titled "Navigate Treatment Options" which provides addiction and treatment FAQs. It evaluates new methods based on developments in neurobiology and behavioral health. It integrates best practices within the bio-psycho-social-spiritual treatment model.

American Addiction Centers provides "Treatment Solutions," an online resource dedicated to helping people find solutions to meet their specific treatment needs. Its website describes how and where to locate free or low-cost drug rehabilitation programs and highlights options for state-funded drug treatment programs, who qualifies for services, and how to local find state-funded treatment options. It also gives information about other possible payment options for treatment such as scholarships, loans, insurance, and how to ask friends and family for support. American Addiction Centers also provides a succinct overview of SAMHSA programs, grants, and treatment services.

Futures Recovery Healthcare has a useful infographic and a variety of information on various types of resources related to drug & alcohol counseling.

The Rural Health Information Hub provides an evidence-based toolkit on effective methods of increasing residential education and awareness of substance use disorder and its impact. This covers methods that utilize print and digital media, mass media, and meetings and conferences.

Advanced Recovery Systems is a behavioral health company focused on helping people on their path to recovery from substance abuse and mental health issues. It operates a network of inpatient and outpatient addiction and mental health treatment facilities and hosts a website that provides a assistance in navigating insurance for treatment. and a tool that checks if your insurance provider covers addiction care.

Pew Trusts 10 Ways That States Can Improve Substance Use Treatment.

Apps and Online Resources:

• Life Recovery Program is an online program that could be a useful option for people who live in rural areas or for people who are incarcerated. The program consists of bi-weekly online video/audio workshops and practical tools, along with homework exercising, grounding techniques, and supportive emails. It is designed to last 3 to 6 months.
• myStrength is an online and smartphone platform that can enhance the capacity of mental health service providers by enabling them to serve more people more effectively. It can also provide tools to support people between professional consultations. There is solid and growing research on the value and effectiveness of the platform.
• reSET-O. Digital Therapeutics Alliance developed this eFORMULATIONS treatment tool for opiate dependence. It is a mobile medical application that is used in conjunction with pharmaceutical therapies to treat opioid dependence. Clinical trials have shown reSET-O to be a promising solution to opiate dependence, showing that reSET-O plus pharmacotherapy achieved enhanced abstinence from opioids, reduced drop-outs in treatment, and reduced required clinical intervention when compared to traditional face-to-face therapy.
• ShoutOut is an app developed by Recovery Centers of America Telehealth. It delivers comprehensive and evidence-based outpatient treatment for addiction and co-occurring disorders. There are three available levels of treatment available to serve each individual’s needs. Group, individual, and family options are implemented into the program.

Promising Practices

Kentucky. In Kenton County, the prison has become an important treatment facility. Instead of focusing on punishing people with substance use issues, the Kenton County Detention Center envisions turning a time of incarceration into a time for much-needed treatment. Leaders in Kenton County believe that jail may be the best place to initiate recovery. People often end up in jail for minor crimes, long before they commit more serious crimes which warrant a prison sentence. Kenton County is one of over 20 Kentucky county jails that have started full-time therapeutic communities that focus on rehabilitation within their walls, providing inmates the type of services that private treatment centers offer on the outside.

Maryland. The Baltimore County Health Department provides treatment through community providers for substance users and their families. It develops, coordinates, and monitors a countywide network of substance use prevention and disorder treatment services. The Health Department also operates a dedicated phone line staffed with clinical social workers with specialized training in helping people with substance use issues move toward recovery.

Massachusetts. Boston Medical Center opened its Faster Paths to Treatment Opioid Urgent Care Center in 2016. This center, which is specifically for treating patients addicted to prescription painkillers, is located next to the hospital emergency room, giving patients immediate access to comprehensive care including counseling, case management, home visits, and transportation to detox.

American Addiction Centers promotes the benefits of group therapy, when led by a trained professional, to include, but not limited to: recovery education, social support, and motivation in recovery, observing various issues and methods within recovery, peer empowerment, and feedback, learning healthy coping skills, and build a sense of optimism, self, and connectedness.

Therapeutic Community (TC) is long-term residential treatment model that is whole-person centered: Labeled the best-known residential treatment model by the NIDA-NIH, TC's are 6-12 months long and focus on “resocialization” of the patient and “use of the program’s entire community - including other residents, staff, and the social context - as active components of treatment.” TC is highly structured and sometimes “confrontational,” as it moves towards developing accountability, responsibility, and productivity. In TC, residents will confront harmful beliefs, ideas, self-views, and behavior patterns while learning to replace these with healthier behaviors, cognitions, and habits. TC may include other support services to aid in the transition.

The University of Pittsburgh Graduate School of Public Health expanded tele-treatment for addiction post-COVID-19. This expansion helped to address gaps in service. It allows for more far-reaching and equitable access to treatment and support Noted benefits of tele-treatment during the pandemic included virtual initiation of treatment, relaxed restrictions that allowed for more access, contactless medication pick-up, and ease of virtual therapy and group meetings.