Introduction
Addiction is a chronic medical illness that affects millions of people all over the world, as well as their families and communities. In 2018, about 2.1 million Americans ages 12 or older had an opioid use disorder (an active opioid addiction). Like diabetes or heart disease, there is no cure for addiction. But it can be managed, and people with addiction can and do recover.
There are treatments available that are proven to be safe and effective. Treatment provided by trained clinicians can lead to a healthier way of life, free from the symptoms of addiction. This healthy way of life is referred to as recovery. Treatment with a medication along with counseling and other support is often the most effective choice for opioid addiction.
This document provides facts about treatment from The American Society of Addiction Medicine (ASAM) – the leading medical society for addiction treatment. Learn more about ASAM at www.ASAM.org.
Definition of Addiction*
Addiction is a treatable, chronic medical disease in which a person compulsively seeks and uses substances like drugs or alcohol, or engages in other behaviors (such as gambling) despite the harms that it causes to their health and/or their life. It is a brain disease because addiction changes how the brain works. Addiction impacts areas of the brain that control motivation, impulse control, reaction to stress, memory, and decision-making. These changes may last a long time, even after the person stops using substances. Without treatment and recovery support, addiction may keep getting worse.
*Modified from ASAM Definition of Addiction
https://www.asam.org/Quality-Science/definition-of-addiction
Assessment
Seeking help is the first important step to recovery. The next step in the process is to meet with a qualified clinician. A clinician is a health professional such as a physician, psychiatrist, psychologist, social worker, or nurse. During this first appointment, the clinician will screen the patient for an opioid use disorder and complete an assessment. The goal of the assessment is to gain a thorough understanding of patients and the severity of their illness. This will help the clinician and patient develop a treatment plan that best matches the patient’s needs.Getting Started
- The clinician will ask questions to understand all of the factors that contribute to the patient’s addiction. The more that is known, the better treatment can be planned with the patient. The patient will likely be asked about:
- Current drug and alcohol use
- Withdrawal symptoms
- History of substance use
- Family history of addiction
- Mental or physical health problems
- Support system
- Available safe, stable housing
- Motivation to change
- The next step is a complete physical examination to check the patient’s overall health. This includes finding other common conditions (physical or mental) related to addiction that may impact the plan for treatment.
- The physical examination will often include a drug test.
Treatment Overview
During the assessment, the clinician will also identify the patient’s psychological and social support needs. They will likely recommend counseling or recovery support services, such as mutual support group participation. However, participation in counseling and other support services should not be required to receive treatment with medication. If the patient does participate in mutual support groups it is important to find a group that is supportive of the use of medications for opioid use disorder.
While a comprehensive assessment and medical evaluation are important for developing a treatment plan, completion of all assessments should not delay or prevent the patient from starting medication.
After the assessment, the clinician will discuss all recommended treatment options with the patient. Every patient situation is different, so choosing the best options is a shared decision between the patient and the clinician.
There are three main choices for medication to treat opioid addiction: methadone, buprenorphine and naltrexone. These medications are typically recommended in combination with counseling and other support services.
There are a range of different treatment options depending on the severity of the patient’s illness and other factors. ASAM describes four broad levels of care:
- ASAM Level 1 - Outpatient treatment. For example, treatment with buprenorphine or naltrexone with a primary care provider.
- ASAM Level 2 - Intensive outpatient or partial hospitalization. In an intensive outpatient program the patient receives over 20 hours per week of treatment services.
- ASAM Level 3 - Residential treatment. Residential treatment programs provide treatment in a safe, homelike setting where the patient can practice skills needed for recovery.
- ASAM Level 4 - Hospital inpatient treatment. Inpatient treatment may be needed for patients with severe medical or psychiatric problems that require medical and nurse care.
It’s important to discuss the many different treatment options with the clinician to determine which is most appropriate.
Treatment Plan
- After discussing the assessment results and treatment choices with the clinician, it’s time to develop the full treatment plan.
- It is common for both the patient and clinician to sign an agreement about what to expect during treatment. This can include:
- Treatment goals
- Medications: usually methadone, buprenorphine or naltrexone for opioid use disorder
- Treatment schedule
- Counseling plan
- Recovery support services
- Patient commitment to cooperate with treatment
- Risks of relapse and other safety concerns.
Patient Participation
- Patient engagement in treatment and recovery improves outcomes. Treatment should be long term, since addiction is a chronic disease. For this reason, it is important that patients work with the clinicians to develop a treatment plan that is tailored to their needs and goals.
- Patients should expect to be treated with respect and dignity and have their concerns listened to when starting or changing the treatment plan.
- To avoid health problems, patients must let their clinicians know about any other medications they are taking or if they drink alcohol. This is very important – certain medications and alcohol can cause major problems with treatment medications.
- Common patient responsibilities include:
- Keeping all appointments
- Providing samples for drug testing on a regular basis
- Taking medications as prescribed
- Using only medications that are prescribed
- Allowing and encouraging involvement of supportive family and friends
- Avoiding persons, places and situations that may put them at risk of relapse.
Counseling
- Counseling is an important part of treatment for many patients and is usually recommended with medications.
- Counseling should be provided by a qualified clinician. Patients may receive counseling in the same place where they receive medication or in another location.
- Counseling helps patients address personal, social or other problems that may contribute to their addiction. Examples can be:
- Increasing motivation for treatment and recovery
- Difficult situations at work or home
- Building a support system of people who are supportive of recovery
- All of the clinicians involved in patient treatment should work together to coordinate care.
- In addition to counseling, patients are encouraged to join support groups that include others who are also in recovery.
- Counseling and support groups are not limited to the patient. There are also many counseling services and support groups for family and friends of those dealing with addiction. Remember, addiction affects friends and family as well.
Support from Family and Friends
- Families and friends can play a key role in supporting their loved ones to achieve a long-lasting recovery.
- It is very important that patients avoid the people, places and other things that trigger their desire to use alcohol or drugs. They also need to learn how to respond to those triggers without using alcohol or drugs. Friends and family can provide support and encouragement throughout this process.
Withdrawal
- Opioid withdrawal refers to the wide range of painful and unpleasant symptoms that occur after stopping or cutting down on the use of opioids. Withdrawal can last more than 10 days but is most often between 3–5 days.
- Although it can cause very troubling symptoms (such as vomiting, cramps and sweating), opioid withdrawal is rarely life-threatening.
- Using medications to control withdrawal (also called withdrawal management) is almost always recommended over trying to endure withdrawal without treatment. When patients do try to stop using opioids without treatment it can lead to stronger cravings and continued use.
- Withdrawal management on its own is not a treatment for opioid addiction and may increase the risk of relapse, overdose, and overdose death.
- When treating someone for opioid addiction, medication (methadone, buprenorphine, or naltrexone) in combination with counseling and other support is usually recommended.
- Lofexidine and clonidine are safe and effective for management of opioid withdrawal, but methadone and buprenorphine are more effective and can be continued for the treatment of opioid addiction.
- Opioid withdrawal management using ultra-rapid opioid detoxification (UROD) is not recommended due to high risk for adverse events including death.
