Treatment for Substance Use Disorders


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Page last updated Oct. 11, 2020 by Doug McVay, Editor/Senior Policy Analyst.

61. Public vs. Private Insurance

"One of the main reasons for the higher outlay in public spending is the frequently limited coverage of substance abuse treatment by private insurers. Although 70 percent of drug users are employed and most have private health insurance, 20 percent of public treatment funds were spent on people with private health insurance in 1993, due to limitations on their policy (ONDCP, 1996b). In the view of the Panel, private insurers should serve as the primary source of coverage, with public insurance serving as the safety net."

US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, "Changing the Conversation: Improving Substance Abuse Treatment: The National Treatment Plan Initiative; Panel Reports, Public Hearings, and Participant Acknowledgements" (Washington, DC: SAMHSA, November 2000), p. 12.

62. Cost Savings of Treatment vs Enforcement

"An additional cocaine-control dollar generates societal cost savings of 15 cents if used for source-country control, 32 cents if used for interdiction, and 52 cents if used for domestic enforcement. In contrast, the savings from treatment programs are larger than control costs: an additional cocaine-control dollar generates societal cost savings of $7.48 if used for treatment."

Rydell, C.P. & Everingham, S.S., "Controlling Cocaine," Prepared for the Office of National Drug Control Policy and the United States Army (Santa Monica, CA: Drug Policy Research Center, RAND Corporation, 1994), p. 42.

63. Drug Treatment Admissions and Incarceration Rates

"Increased admissions to drug treatment are associated with reduced incarceration rates. States with a higher drug treatment admission rate than the national average send, on average, 100 fewer people to prison per 100,000 in the population than states that have lower than average drug treatment admissions. Of the 20 states that admit the most people to treatment per 100,000, 19 had incarceration rates below the national average. Of the 20 states that admitted the fewest people to treatment per 100,000, eight had incarceration rates above the national average."

Justice Policy Institute, "Substance Abuse Treatment and Public Safety," (Washington, DC: January 2008), p. 2.

64. International Drug Conventions and Heroin-Assisted Treatment

"Many countries believe (erroneously) that the international drug conventions prohibit the use of heroin in medical treatment. Furthermore, the International Narcotics Control Board (INCB) has exerted great pressure on countries to cease prescribing heroin for any medical purpose. Nevertheless, a few countries, including the UK, Belgium, the Netherlands, Iceland, Malta, Canada and Switzerland, continue to use heroin (diamorphine) for general medical purposes, mostly in hospital settings (usually for severe pain relief). Until recently, however, Britain was the only country that allowed doctors to prescribe heroin for the treatment of drug dependence."

Stimson, Gerry V., and Nicky Metrebian, Centre for Research on Drugs and Health Behavior, "Prescribing Heroin: What is the Evidence?" (London, England: Rowntree Foundation, 2003), p. 4.

65. Drug Offenders Sentenced to Treatment

"In 2006 an estimated 38% of persons sentenced for a felony in state courts were ordered to pay a fine as part of their sentence (table 1.5). Approximately 1 in 4 property offenders was ordered to make restitution and 23% of offenders convicted of drug possession were sentenced to treatment."

Sean Rosenmerkel, Matthew Durose and Donald Farole, Jr., "Felony Sentences in State Courts, 2006 –Statistical Tables," Bureau of Justice Statistics (Washington, DC: US Department of Justice, December 2009), p. 2.

66. Addiction as a Public Health Rather Than Criminal Justice Issue

"The Panel anxiously awaits the time when the disease of addiction is no longer treated as a criminal justice issue, but as a public health problem. Moreover, the Panel embraces the notion of a society that enables any individual with a substance abuse problem, regardless of criminal history, to receive treatment in a safe and respectful environment. The Panel hopes to create a climate in which people who are at risk for, suffering from, or in recovery from alcohol or other drug addiction are valued and treated with dignity."

US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, "Changing the Conversation: Improving Substance Abuse Treatment, The National Treatment Plan Initiative; Panel Reports, Public Hearings, and Participant Acknowledgements," (Washington, DC: SAMHSA, November 2000), p. 41.

67. Types of Treatment

"Currently, pharmaceutical treatment for substance abuse addiction in the United States is limited to two basic types: (1) replacement therapy; and (2) aversion therapy.21 Replacement therapy is characterized by substituting or replacing the drug that the person is addicted to with a “safer drug” under the theory that the individual can be weaned off the replacement drug over time.22 The most prominent examples of this are methadone maintenance for heroin addiction and nicotine replacement drugs for smokers.23 Unfortunately, there are no “safer drugs” available for individuals with addictions to cocaine, crack, or methamphetamine.24"

"Aversion therapy, on the other hand, involves the use of drugs that interact negatively with the drug of addiction, such as disulfiram, which is used to treat alcoholism.25 This treatment choice posits that the individual will be deterred from using the drug to which they are addicted because, when combined with aversion drugs, it induces nausea, vomiting, and physical pain.26 The problems associated with these treatment methods, however, are numerous. Both require long-term treatment, which greatly increases the chance that an addict will quit treatment and return to using.27 Replacement therapy simply replaces one drug with another, and, as is the case with methadone, the “safer drug” is itself addictive. ... The unpleasant side effects associated with aversion therapy, however, result in many patients stopping treatment and relapsing.31"

Donnelly, Jennifer R, "The Need for Ibogaine in Drug and Alcohol Addiction Treatment," The Journal of Legal Medicine (Schaumburg, IL: American College for Legal Medicine, March 2011), Vol. 32, Issue 1, pp. 96-97.

68. Economic Benefits from Substance Use Disorder Treatment

"The cost of proven treatment for inmates, accompanied by appropriate education, job training and health care, would average about $6,500 per year. For each inmate who successfully completes such treatment and becomes a taxpaying, law-abiding citizen, the annual economic benefit to society--in terms of avoided incarceration and health care costs, salary earned, taxes paid and contribution to the economy--is $68,800, a tenfold return on investment in the first year. If a year of such comprehensive treatment turns around only ten percent of those who receive it, it will pay for itself within the next year. Even with the difficult inmate population, success rates are likely to reach at least 15 percent of those who receive such treatment and training."

National Center on Addiction and Substance Abuse at Columbia University, Behind Bars: Substance Abuse and America's Prison Population, (New York, NY: National Center on Addiction and Substance Abuse at Columbia University, January 8, 1998), Foreword by Joseph Califano, p. iii.

69. Cannabis Substitution Treatment

"Only orally given THC and, to a lesser extent, nefazodone have shown promise [in treating marijuana dependence]. THC reduced craving and ratings of anxiety, feelings of misery, difficulty sleeping, and chills (Haney et al., 2004). In addition, participants could not distinguish active THC from placebo. These findings were replicated in an outpatient study, which found that a moderate oral dosage of THC (10 mg, three times daily) suppressed many marijuana withdrawal symptoms and that a higher dosage (30 mg, three times daily) almost completely abolished withdrawal symptoms (Budney et al., 2007)."

Budney, Alan J.; Roffman, Roger; Stephens, Robert S.; Walker, Denise, "Marijuana Dependence and Its Treatment," Addiction Science & Clinical Practice (Rockville, MD: National Institute on Drug Abuse, December 2007), p. 11.

70. Stigmatization of Substance Addiction

"Changing The Conversation initiated the first intensive exploration of the stigmas and attitudes that affect people with alcohol and drug problems. The Panel addressed stigma as a powerful, shame-based mark of disgrace and reproach that impedes treatment and recovery. Prejudicial attitudes and beliefs generate and perpetuate stigma; therefore, people suffering from alcohol and/or drug problems and those in recovery are often ostracized, discriminated against, and deprived of basic human rights. Their families, treatment providers, and even researchers may face comparable stigmas and attitudes. Ironically, stigmatized individuals often endorse the attitudes and practices that stigmatize them. They may internalize this thinking and behavior, which consequently becomes part of their identity and sense of self-worth.
"Public support and public policy are influenced by addiction stigma. Addiction stigma delays acknowledging the disease and inhibits prevention, care, treatment, and research. It diminishes the life opportunities of the stigmatized."

US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, "Changing the Conversation: Improving Substance Abuse Treatment: The National Treatment Plan Initiative; Panel Reports, Public Hearings, and Participant Acknowledgements" (Washington, DC: SAMHSA, November 2000), p. 38.

71. Reasons for Treatment Completion Disparities

"Using national data, we found that blacks and Hispanics were 3.5–8.1 percentage points less likely than whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percentage points less likely to complete alcohol treatment. Only Asian Americans fared better than whites for both types of treatment. Completion disparities for blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability. However, the alcohol treatment disparity for Native Americans was not explained by socioeconomic or treatment variables, a finding that warrants further investigation."

Brendan Saloner and Benjamin Lê Cook, "Blacks And Hispanics Are Less Likely Than Whites To Complete Addiction Treatment, Largely Due To Socioeconomic Factors," Health Affairs, 32, no.1 (2013):135-145 doi: 10.1377/hlthaff.2011.0983, p. 135.

72. Factors Explaining Disparities in Substance Use Disorder Treatment Outcomes

"Our analysis points to factors that may help explain disparities and guide policy. In particular, when we adjusted for both individual need and provider setting, we found that alcohol treatment disparities widened between whites and blacks and between whites and Native Americans. Blacks and Native Americans also were more likely to be treated in residential settings than were whites, suggesting that higher placement rates in residential treatment for these groups may actually help limit disparities and could compensate for other forms of disadvantage.

"Further adjustment for socioeconomic status narrowed the completion gap between whites and blacks and between whites and Hispanics for both alcohol and drug treatment. This change suggests that housing instability and lower employment are important barriers to treatment completion for blacks and Hispanics. Adjusting for socioeconomic status modestly increased the relative Asian American advantage, probably because if Asian Americans had the same educational attainment as whites, they would fare even better in treatment.

"Our findings linking lower socioeconomic status to worse treatment completion are important. Low socioeconomic status is a known risk factor for poor access to and quality of mental health treatment.30 Nonethless, some studies suggest that low socioeconomic status may, paradoxically, promote greater access to substance abuse treatment for minorities.31 Adjusting for socioeconomic status narrowed white-minority disparities for all groups except Native Americans in alcohol treatment. This finding warrants further investigation, since Native Americans in alcohol treatment were more likely than whites to be unemployed and to have less education."

Brendan Saloner and Benjamin Lê Cook, "Blacks And Hispanics Are Less Likely Than Whites To Complete Addiction Treatment, Largely Due To Socioeconomic Factors," Health Affairs, 32, no.1 (2013):135-145 doi: 10.1377/hlthaff.2011.0983, pp. 140-142.

73. Prescription Injectable Opiates

"Prescribing injectable opiates is one of many options in a range of treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health and social status, our findings endorse the view that it is a feasible option."

Metrebian, Nicky, Shanahan, William, Wells, Brian, and Stimson, Gerry, "Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users; associated health gains and harm reductions," The Medical Journal of Australia (Sydney, Australia: June 1998) Volume 168, Issue 12, pp. 596-600.

74. Heroin Assisted Treatment vs Methadone Maintenance

"The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

Naber, Dieter, and Haasen, Christian, Centre for Interdisciplinary Addiction Research of Hamburg University, "The German Model Project for Heroin Assisted Treatment of Opioid Dependent Patients -- A Multi-Centre, Randomised, Controlled Treatment Study: Clinical Study Report of the First Study Phase," January 2006, p. 122.

75. Heroin-Assisted Treatment and Decline in Problematic Heroin Use

"Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains. Musto's generational theory regards the decline in incidence more as a social learning effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant early experiences to devastating circumstances for addicts, families, and communities later on."

Nordt, Carlos, and Rudolf Stohler, "Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis," The Lancet, Vol. 367, June 3, 2006, p. 1833.

76. Drug Treatment and Crime Reduction

"With respect to the group of those treated uninterruptedly during four years, a strong decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers towards program participants.
"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences were found with regard to in-treatment rates. Taken as a whole, this suggests that the treatment had a somewhat more beneficial effect on men than women. This result is corroborated by self-report data (Killias et al., 2002). With respect to age and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated addicts, this retention rate is, at least, promising."

Ribeaud, Denis, "Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of Treated Heroin Users," Journal of Drug Issues (Talahassee, FL: University of Florida, Winter 2004), p. 187.

77. Reasons for Discontinuing Treatment

"Finally, the analysis of the reasons for interrupting treatment revealed that, even in the group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment – and a fortiori abstinence treatment – is able to substantially reduce acquisitive crime, the redirection of heroin maintenance patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back 'on the street'."

Ribeaud, Denis, "Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of Treated Heroin Users," Journal of Drug Issues (Talahassee, FL: University of Florida, Winter 2004), p. 188.

78. Substitution of Cannabis for Other Drugs

"Eighty five percent of the BPG [Berkeley Patients Group] sample reported that cannabis has much less adverse side effects than their prescription medications. Additionally, the top two reasons listed by participants as reasons for substituting cannabis for one of the substances previously mentioned were less adverse side effects from cannabis (65%) and better symptom management from cannabis (57.4%).
"The substitution of one psychoactive substance for another with the goal of reducing negative outcomes can be included within the framework of harm reduction. Medical cannabis patients have been engaging in substitution by using cannabis as an alternative to alcohol, prescription and illicit drugs."

Reiman, Amanda, "Cannabis as a Substitute for Alcohol and Other Drugs," Harm Reduction Journal (London, United Kingdom: December 2009).