Substance Use Treatment

The treatment system for substance use disorders is comprised of multiple service components, including the following:

Individual and group counseling
Inpatient and residential treatment
Intensive outpatient treatment
Partial hospital programs
Case or care management
Medication
Recovery support services
12-Step fellowship
Peer supports

A person accessing treatment may not need to access every one of these components, but each plays an important role. These systems are embedded in a broader community and the support provided by various parts of that community also play an important role in supporting the recovery of people with substance use disorders.

Individual and Group Counseling

Counseling can be provided at the individual or group level. Individual counseling often focuses on reducing or stopping substance use, skill building, adherence to a recovery plan, and social, family, and professional/educational outcomes. Group counseling is often used in addition to individual counseling to provide social reinforcement for pursuit of recovery.

Counselors provide a variety of services to people in treatment for substance use disorders including assessment, treatment planning, and counseling. These professionals provide a variety of therapies. Some common therapies include:

Cognitive-behavioral therapy teaches individuals in treatment to recognize and stop negative patterns of thinking and behavior. For instance, cognitive-behavioral therapy might help a person be aware of the stressors, situations, and feelings that lead to substance use so that the person can avoid them or act differently when they occur.
Contingency management is designed to provide incentives to reinforce positive behaviors, such as remaining abstinent from substance use.
Motivational enhancement therapy helps people with substance use disorders to build motivation and commit to specific plans to engage in treatment and seek recovery. It is often used early in the process to engage people in treatment.
12-step facilitation therapy seeks to guide and support engagement in 12-step programs such as Alcoholics Anonymous or Narcotics Anonymous.

Some forms of counseling are tailored to specific populations. For instance, young people need a different set of treatment services to guide them towards recovery. Treatments for youth often involve a family component. Two models for youth that are often used in combination and have been supported by SAMHSA grants are the Adolescent Community Reinforcement Approach (ACRA) and Assertive Continuing Care (ACC). ACRA uses defined procedures to build skills and support engagement in positive activities. ACC provides intensive follow up and home based services to prevent relapse and is delivered by a team of professionals.

Inpatient and Residential Settings

Treatment can be provided in inpatient or residential sessions. This happens within specialty substance use disorder treatment facilities, facilities with a broader behavioral health focus, or by specialized units within hospitals. Longer-term residential treatment has lengths of stay that can be as long as six to twelve months and is relatively uncommon. These programs focus on helping individuals change their behaviors in a highly structured setting. Shorter term residential treatment is much more common, and typically has a focus on detoxification (also known as medically managed withdrawal) as well as providing initial intensive treatment, and preparation for a return to community-based settings.

An alternative to inpatient or residential treatment is partial hospitalization or intensive outpatient treatment. These programs have people attend very intensive and regular treatment sessions multiple times a week early in their treatment for an initial period. After completing partial hospitalization or intensive outpatient treatment, individuals often step down into regular outpatient treatment which meets less frequently and for fewer hours per week to help sustain their recovery.

Medication

Using medication to treat substance use disorders is often referred to as Medication-Assisted Treatment (MAT). In this model, medication is used in combination with counseling and behavioral therapies. Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken. MAT is has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders.

Medications for Alcohol Use Disorders

Medications also exist that can assist in the treatment of alcohol use disorder. Acamprosate is a medication that reduces symptoms of protracted withdrawal and has been shown to help individuals with alcohol use disorders who have achieved abstinence go on to maintain abstinence for several weeks to months. Naltrexone, a medication used to block the effects of opioids, has also been used to reduce craving in those with alcohol use disorders. Disulfiram is another medication which changes the way the body metabolizes alcohol, resulting in an unpleasant reaction that includes flushing, nausea, and other unpleasant symptoms if a person takes the medication and then consumes alcohol.

Medications for Tobacco Use Disorders

There are three medications approved by the Food and Drug Administration (FDA) to treat tobacco use disorders (cigarette smoking). Nicotine replacement medications assist with reducing nicotine withdrawal symptoms including anger and irritability, depression, anxiety, and decreased concentration. Because nicotine delivered through chewing of gum containing nicotine, via transdermal patch, or in lozenges has a slower onset of action than does the systemic delivery of nicotine through smoked tobacco; these medications have little effect on craving for cigarettes. These medications are available over-the-counter. However, the nicotine inhaler and nasal spray deliver nicotine more rapidly to the brain and so are available only by prescription. Bupropion is a medication originally developed and approved as an antidepressant that was also found to help people to quit smoking. This medication can be used at the same dose for either cigarette smoking or depression treatment (or both). Varenicline is a nicotine partial agonist that reduces craving for cigarettes and has been helpful in smoking cessation for many. Bupropion and varenicline are prescription medications.

Medication for Opioid Use Disorders

Medication-assisted treatment with methadone, buprenorphine, or extended-release injectable naltrexone plays a critical role in the treatment of opioid use disorders. According to the latest survey of opioid treatment providers more than 300,000 people received some form of medication-assisted treatment for an opioid use disorder in 2011.

Opioid agonist therapies with methadone or buprenorphine reduce the effects of opioid withdrawal and reduce cravings. They have been shown to increase retention in treatment and reduce risk behaviors that lead to transmission of HIV and viral hepatitis such as using opioids by injection.

Medication-assisted treatment with extended-release injectable naltrexone reduces the risk of relapse to opioid use and helps control cravings. Extended-release injectable naltrexone is particularly useful for people exiting a controlled setting where abstinence has been enforced such as jail or residential rehabilitation or in situations where maintenance with an opioid agonist is not available or appropriate. People who misuse prescription opioids benefit from medication assisted treatment as much as people abusing heroin.

There are no other FDA-approved medications for the treatment of other substance use disorders.

More information about medication-assisted treatment is available through SAMHSA’s Addiction Technology Transfer Center Network(link is external).

Recovery Support Services

Recovery support services are non-clinical services that are used with treatment to support individuals in their recovery goals. These services are often provided by peers, or others who are already in recovery. Recovery support can include:

Transportation to and from treatment and recovery-oriented activities
Employment or educational supports
Specialized living situations
Peer-to-peer services, mentoring, coaching
Spiritual and faith-based support
Parenting education
Self-help and support groups
Outreach and engagement
Staffing drop in centers, clubhouses, respite/crisis services, or warmlines (peer-run listening lines staffed by people in recovery themselves)
Education about strategies to promote wellness and recovery

Peer Supports

Peers are individuals in recovery who can use their own experiences to help others working towards recovery. Peer supports are a critical component of the substance use disorder treatment system. Many people who work in the treatment system as counselors or case managers are in recovery, and peers are central to many recovery support efforts.

Peers also play a powerful role as a part of mutual-support groups. These groups, including Alcoholics Anonymous or Narcotics Anonymous and other 12-step programs, provide peer support for ending or reducing substance use. They provide an international support network which is relied upon by many people in recovery from substance use disorders. Mutual-support groups are often intentionally incorporated into treatment plans and can provide a ready community for individuals who are trying to change their lifestyles to get away from alcohol and other drugs. While mutual-support groups do not work for everyone and are not a necessary part of recovery, they are a fundamental component of the substance use disorder treatment system, even if they are not considered formal treatment.

Resources for Specific Substance Use Disorders

Alcohol Use Disorder

Learn more about medications that can be used to treat alcoholism from the SAMHSA publication Incorporating Alcohol Pharmacotherapies into Medical Practice – 2009.

Cannabis Use Disorder

The Cannabis Youth Treatment Series is a five-volume resource for substance abuse treatment professionals that provides a unique perspective on treating adolescents for marijuana use.

SAMHSA also developed the Brief Counseling for Marijuana Dependence: A Manual for Treating Adults – 2005, which guides practitioners on how to help adult patients reduce or stop marijuana use through skill building.

Stimulant Use Disorder

One of the best-known treatment interventions is the Matrix Model, an outpatient treatment approach that was developed during the mid-1980s. SAMHSA has developed a set of materials about the Matrix Model.

SAMHSA’s Treatment Improvement Protocol (TIP) #33: Treatment for Stimulant Use Disorders – 2009 contains comprehensive information on all aspects of stimulant abuse, including treatment.

Opioid Use Disorder

Two volumes in the SAMHSA Treatment Improvement Protocol (TIP) series focus on opioid treatment:

Other SAMHSA materials also provide information about treatment for opioid use disorder:

Sources: https://www.samhsa.gov/treatment/substance-use-disorders