Treatment of Substance Use Problems

Formal treatment can help the initiation of recovery from addiction, facilitating a self-healing process, and help a person minimise the harms from their substance use (2,600 words).

1. Nature of the problems
The vast majority of people who try illicit drugs or drink alcohol do not go on to experience problems. However, a significant minority do experience problems that eventually impact negatively on their physical and mental health and their social circumstances.

This harm can arise from the direct negative effects of drugs (e.g. long-term alcohol causes liver damage), indirect effects arising from repeated withdrawal symptoms (e.g. depression from long-term cocaine use), and the negative effects arising from the lifestyle associated with illegal street drugs (e.g. homelessness).

Long-term drug or alcohol use can lead to dependence or addiction. In simple terms, addiction can be seen as an impairment of a person’s ability or power to choose. The substance becomes more important than other aspects of their life, which the majority of people would consider as essential. Addiction drives forward heavy and persistent substance use, ultimately increasing the incidence of harm.

Addiction is a complex condition involving biological, psychological and sociological components that represents a major challenge to treatment practitioners. Unfortunately, there are no magic bullets or simple interventions that are all embracing in the treatment of addiction.

2. Nature of treatment
Drug and alcohol treatment services exist primarily to help and support those people who develop problems from their use of drugs and/or alcohol. A range of services and agencies has evolved that aim to reduce the harm that individuals cause to themselves.

Treatment may involve clients abstaining from drugs or alcohol completely, or may involve a form of harm minimisation, such as encouraging clients to use clean needles to inject in order to minimise the risk of infections, such as HIV or hepatitis.

People present for treatment, advice and support at various stages of their substance-using career. Therefore, treatment agencies need to be able to respond to a variety of different situations that may involve different interventions.

Some people who use drugs recreationally may only require information and advice from a treatment agency. Others can be helped by a brief intervention. For example, a brief intervention may involve the assessment of alcohol intake and alcohol-related problems, followed by information about how to cut down on drinking.

Some people present for treatment with severe substance use problems. A significant proportion of these people present with a variety of other intimately related problems. They may be homeless, jobless and experiencing problems with personal relationships, have a history of criminal activity, and have a physical and/or mental health problem.

People with severe substance use problems often require an extensive package of treatment and aftercare, sometimes involving medical, psychological and social interventions. The importance of aftercare should not be under-estimated. It is much easier to stop, than to stay stopped.

It is widely accepted that the best approach to treating a person with a serious substance use problem is to treat the individual as a whole (holistically), rather than simply focusing on trying to reduce his or her intake of substances. Thus, in trying to help people overcome their substance use problem, treatment services may need to help clients access other forms of support, such as housing services, social services, mental health services, education and vocational training.

Practitioners must also be aware that relapse is a common attribute of addiction. Some people remain abstinent for many months or years before initiating substance use again, whilst others continue to periodically pop in and out of treatment agencies over long periods of time.

Other people who visit a treatment agency permanently abstain from drugs and alcohol and go on to lead full and healthy lives. In fact, their recovery may represent a better life than they had prior to developing their substance use problem.

Many people seek out treatment services because they want to stop using substances, but believe they cannot do it themselves. They look to other people to help them overcome their substance use problem. Some of these people find they cannot just stop using—they may have tried on many occasions—so it is essential they receive support that helps them minimise the harm that drugs and the drug-using lifestyle cause them.

They may decide after an initial visit to a treatment agency to use needle exchange facilities, and at a later stage feel ready to engage in a methadone programme. Some time later, they may decide that they want to be abstinent from all substances, but this process may involve various stages.

Some people access treatment because they are seeking relief from the discomfort or pressures of a drug-using lifestyle. The day-to-day existence of someone with a serious substance use problem can be tough and the person may look to others for help in dealing with the problems in their life.

Treatment agency workers can support users through periods of crisis, e.g. helping them deal with homelessness, problems receiving benefits, or health problems. Often their role will involve facilitating access to others who can provide more direct help.

In these circumstances, agency workers can take the opportunity to engage users in other services, educate the user about harm minimisation, and try to enhance motivation for behavioural change. This support can be critical in the early stages of a person’s recovery journey.

3. Changing behaviour and recovery
Many factors moderate the development of an addiction to substances, and help create exits from initial engagement and problematic use. In general, people are less likely to become addicted to substances if they have few life problems, and good personal and social resources, such as healthy self-esteem, strong family relationships, and non-drug using friends. In addition, if a person can find satisfaction and happiness in other activities, they are less likely to become addicted.

In general, people are more likely to become addicted to substances if they have complicated personal problems (e.g. depression), few personal resources (e.g. low self-esteem), and live in a deprived social environment offering few alternative pleasurable activities. Serious substance use problems often occur as part of a larger cluster of psychological, physical, family and social problems.

A variety of factors can change problematic substance use once it has developed. For some people, the problems are transitional in nature and they mature out of them as their setting changes, e.g. other life events become more significant, such as setting up a home with a loved one. Other people spend years misusing substances and suffering negative consequences and losses, before dying without overcoming their problems.

For most people, however, their substance misuse involves multiple attempts either to stop using or to bring their use under better control. The majority of people eventually resolve their substance use problems, often on their own without formal treatment.

In general, it is easier to resolve substance use problems at earlier and less severe stages of problem development. For some people, reduced use or abstinence can be triggered by relatively brief interventions, the impact of which is thought to be on the person’s motivation for, and commitment to, change.

A common obstacle to early help-seeking is ambivalence and the perception that one does not have a“problem” serious enough to warrant change or treatment. Once this ambivalence is resolved and a commitment made, change may proceed without much additional support.

For other people, their problematic substance use is part of a larger cluster of life problems that can become very resistant to change. Family factors and social networks may be central in establishing and maintaining the substance misuse. It is important to understand what maintains substance use in these individuals and, more importantly, establish which components need to be addressed to produce stable change.

Recovery is a word used to describe the process through which individuals with serious substance use problems resolve these problems and establish a meaningful and fulfilled life. Recovery involves the development and use of coping strategies and techniques that reduce a person’s vulnerability to relapsing back into problematic use.

Recovery, or overcoming problematic substance use, is rarely an isolated event. A person may make a number of attempts to stop using a substance before they finally stop permanently. Each of the attempts at stopping involves events and processes that the person can learn from and that can ultimately contribute to recovery.

There are many different ways that people overcome addiction, and no two people take identical pathways to recovery.

However, there are four main types of help that facilitate recovery. These include the person using:

  • their own strengths and resources
  • the help of family members and other loved ones
  • support groups in the community (e.g. Alcoholics Anonymous)
  • formal treatment.

People may utilise these different types of help at different times in their path to recovery. Some may find one type of help more beneficial than others, although this may change over time. For example, treatment may play a large role at the beginning of the recovery process, whereas later on help may be sought from loved ones and friends during difficult periods.

Whilst there are many routes to recovery, they all have two things in common. Firstly, they all come from within the person. Self-change is the foundation and the process underlying all recovery.

Formal treatment is a time-limited, circumscribed experience or series of experiences that interacts with and hopefully enhances the self-change process on the way to recovery. Treatment can facilitate the initiation of recovery, but is not in a person’s life long enough to produce long-term recovery. The initial ‘gains’ facilitated by treatment in the early stages of recovery are built upon by the person’s interactions in their social environment and facilitated by recovery-related resources in the community.

Secondly, all routes to recovery involve behavioural change. A change from a problematic behaviour to one that is healthier for the person concerned.

In general, people pass through a sequence of stages on the way to resolving substance use problems. In brief, they:

  • become concerned about the need to change;
  • become convinced that the benefits of change outweigh the costs, and make the decision to change;
  • create and commit to a feasible and effective plan of action;
  • carry out the plan by taking the actions needed to make the change;
  • and, consolidate the change into a lifestyle that can sustain the change.

A person may move forward and backwards between the stages on many occasions, before they finally achieve a sustained recovery.

A variety of processes, occurring within the person and in their environment, combine to help them move through the stages of change. Achieving and maintaining change depends on using the right processes at the right time. This can help explain why it can often take a person numerous attempts to overcome their substance use problem.

4. Seeking and accessing help
Harald Klingemann and colleagues in their book, Promoting Self-change from Problem Substance Use, provide an excellent overview of the behavioural change process from the viewpoint of the individual, in terms of whether the person will seek help, what type of help they will seek, and why. They look at the factors that are likely to influence a person’s decision about what recovery route to pursue.

‘These factors, which operate in selecting the general route of change and the specific method within that route, range from personal beliefs and experiences to practical issues, and to community structure and attitudes.’  

Once a person has made a decision to attempt to change, the ways they approach this objective must start from their knowledge about how to change and what assistance might be available. This knowledge is derived from general information and help that is available, and from knowing the experiences of other people in a similar situation.

Klingemann and colleagues describe six ‘information/knowledge’ factors that are likely to influence decisions about what route of change to pursue:

  • Treatment programmes
  • How others have changed
  • Self-help group existence and local availability
  • Trusted others available to provide informal counsel
  • Professional services available
  • How people recover from substance use problems.

Sadly, there is little quality information related to these factors that is freely available to help people affected by substance use problems.

Environmental factors also influence decisions about which change routes to select. Firstly, there is the availability of treatment services, self-help groups, and counselling and other support services. This availability varies greatly, particularly between urban and rural areas. Secondly, the ease of access to services plays an important role, with waiting times and transportation being important.

Thirdly, community attitudes towards substance use problems play a major role. We live in a highly prejudicial society and this can influence whether people access treatment and the ease with which they can recover from addiction. For example, it has been shown that a key element underlying recovery is being considered ‘normal’ by so-called normal society. A society that stigmatises people who have a substance use problem is not likely to facilitate their efforts to find recovery.

Fourthly, a treatment system that operates within the criminal justice system is only going to attract certain types of client: it will miss many potential clients who fear they will be labelled as criminals if they access treatment. (At one time in the UK, the criminal justice system so dominated much of the treatment system that people used to say that the fastest way to get into treatment was to throw a brick through a window—and some people were so desperate for faster help they did this!)

A variety of individual factors influence choice of change route. Many of the change routes involve personal costs that the person may or may not find worthwhile. Treatment programmes and self-help groups can involve a commitment of time that conflicts with other responsibilities (e.g. looking after young children) or activities (e.g. work). Some treatment programmes (e.g. private residential care) may involve a financial commitment that a person may not be able to afford.

Klingemann and colleagues point out that these factors serve to make the individual aware of a menu of choices and a set of costs and benefits related to each choice. The person will weigh up these costs and benefits and make a decision whether they want to change.

However, the resultant choice is made against a backdrop of psychological factors.

‘Individual differences in traits, attitudes, backgrounds, preferences, values and the other factors that combine to yield our idiosyncratic identities will ultimately serve as the filtering mechanisms through which choice merges.’ 

These psychological factors include:

  • Attitude towards independence
  • Trust of others to give aid
  • Beliefs about how one should recover
  • Past experiences.

Understanding how people decide what route to try to change—and providing relevant high quality information so they can make informed decisions—is extremely important in delivering treatment and other support services. Ultimately, demand for treatment will always outstrip supply, so we need to optimise the way that we help people find recovery.