Hello everyone and welcome back. In our past sections we have been discussing aspects of screening and assessment. In this section we begin discussing treatment models that are available for substance abuse treatment.

So let's begin by going to slide two. First of all as we can see here, there are many approaches one can use for treatment. These treatment approaches have been around for thousands of years. Hippocrates, for example, used vegetarianism, sexual abstinence, meditation, and many other things. However it was not very successful in resolving the issues. In the middle ages we changed the model to using prayer by the person themselves or by others for the person, and when all else fails we blamed the witches for the person remaining a substance abuser.

Other techniques as we see in slide three have been around as well. For example, abstinence has been used over the ages. In addition to that we have also tried prohibition, such as banning the substance and this actually caused the Opium Wars with China and Great Britain. Elixirs have also been around for a while and these have been used for a while to decrease symptoms or as a substitute for the addiction. For example, cocaine has been used for many years and was actually a part of many products up until the early 1900's. Alcohol was also mixed with morphine and created the first real anesthetic called Laudanum. You might see that in some of the old movies. There were a variety of other techniques as well.

Hospitals were also used. Often alcoholics were placed in mental hospitals because alcoholism, at the time, was considered a mental disease. And, it showed classic symptoms of mental disease including withdrawal symptoms, loss of control, ignoring family responsibilities, and other symptoms. So in a consequence, individuals of the time treated it like one. The focus was on getting the person to stop drinking. However, the problem for the addictions hospitals is that there was no real formalized treatment. And there were no real addictions treatment counselors at the time either, and of course nothing really worked. The alternative for all these problems as seen in slide five was to ban the substance and the Harrison Narcotic Act of 1914 did just that. It banned all narcotics and major types of drugs, and what it primarily did was put the physicians in charge of prescribing medications.

There is one major issue that one needs to discuss when talking about substance abuse treatment and this is shown in slide six. Basically in relation to comparing whether a treatment is effective or not, you need to look at the baseline of individuals who recover after treatment and in addition to that, many individuals that have mental disorders recover without treatment. This is what is called "Spontaneous Remission". Spontaneous remission occurs in a wide variety of different disorders such as cancers, mental illnesses, and of course, addictions. On average in the addictions community it averages about thirty percent.

Consequently, as we see in slide seven, for any treatment program to be called successful you have to get a significantly better success rate than spontaneous remission. In addition to that the treatment success cannot be measured immediately following the treatment. I have actually seen treatment centers follow up their clients one week later where they would call up the people and say, "How are you doing?" And the person would say, "I'm still not using." And they would call that successful. Generally you need at least one year of follow-up to determine whether or not your program is successful. That requires that you have some kind of ongoing evaluation.

The question is, as we see in slide eight, "What is success?" For some treatment providers and individuals only abstinence is considered successful. For other individuals and other treatment providers, reduction of use is important. Still others, social use, which you do not have any harm, you do not lose control, etc. And for others, you can still use but use some kind of harm reduction measure, such as using clean needles. So ultimately, all these types of successes can have an impact on substance abuse treatment and are used by a wide variety of treatment providers.

So, who provides the treatment and who gets actually paid for doing it? As we can see in slide nine, practically anyone can provide addictions treatment. However that does not necessarily mean the addictions treatment is very good. Other individuals contend that only people who have experienced addiction can actually help an addict. This is still proposed and discussed by many treatment providers in the field. Other providers and professionals contend that individuals with some training can provide addictions counseling treatment and we often see this in many treatment agencies. Or persons with some kind of certification, or a Bachelors degree plus some training, or a Master's degree plus some training, or persons with a Doctoral degree.

The problems with all this as we can see in slide ten; currently any of these groups can get payments and grants to work with addicts. For example, individuals with no training at all such as in Missions, churches, or outreach centers, can often times write grants to help individuals with substance abuse problems. This often occurs in the missions communities. Many treatment centers do not even follow up with their clients to determine if their programs are successful. Consequently, the program model actually becomes more important than client success and getting more money for that. If a person who is a treatment provider in that agency tries to deviate from the model basically they are slapped down pretty hard and if they continue to do so they will not be working with that program. The result of all that is there are many, many programs out there. Some of the programs are very successful, that is, they have better success rates and spontaneous remission. Unfortunately, however, many programs do not have success rates as good as spontaneous remission and some have even less successful rates than spontaneous remission or spontaneous recovery.

So what about individuals with college degrees? Well, college degrees give you a variety of different things, as we see in slide eleven, college degrees give you a base set of knowledge. They teach you how to think and evaluate data. It teaches you how to understand research and how to read the data obtained by the research. The college degree makes you ask the question "Is this model that we are using in our treatment agency actually a good model?"

Let's take an example as in slide twelve. Primal scream therapy has been used in the past and is even used today for depression. Basically, when you are feeling down, feeling blue, or whatever, go outside and scream about the issues. It makes you feel better. The problem is that it does not solve the depression. It also does not resolve the issues underlying the depression. It can also wake up the neighborhood and can get the individual involved with the law enforcement authorities for disturbing the peace.

So basically whatever you use out there as seen in slide thirteen, you need to evaluate and then basically what you need to be doing is evaluating the model you are using for addictions treatment or any other kind of treatment used out there. Some basic questions need to be asked. Does the treatment change the behavior or some other cognitive aspect that is going on with the problem? Does the model have a good success rate for addictions treatment or any other kind of treatment you are going to use it for? Do aspects of the model actually work or do just some of the parts work while other parts need to be improved? Now as we can see at the bottom of this page the is an organization called CSAT, the Centers for Substance Abuse Treatment. What CSAT purposes are that we use best practice models. That is, models that work, depending on whatever the thing out there that one is looking at.

So, what about training of individuals that are going to be giving substance abuse treatment? Well, as we can see in slide fourteen and some other ones following here there is a wide variety of training levels. The first on as seen in slide fourteen is paraprofessional training. Individuals in this group take classes or some kind of workshops which include some very basic skills. These individuals can ultimately become certified that enables them to use them in formalized settings such as addictions treatment program.

Bachelor's level training as seen on slide fifteen is still part of paraprofessional training. Here you have more knowledge related to the theoretical models you will be using in substance abuse treatment. You also have a better understanding of the strengths and weaknesses of each model. However, it does not include formalized training in specific aspects of therapy. You will still need specific training in the specific areas you will be working, whether it is in addictions, public health, social work, etc. Ultimately individuals in this area can get some kinds of certifications and these allow you to work in formalized settings such as addictions treatment centers, mental health centers and it allows you to increase your marketability.

Master's certification as we see in slide sixteen is one of the professionalism degrees in the counseling field. It is more specialized than bachelor's degree programs and it teaches you specific skill sets. So it is going to teach you a specific therapy model and will also give you practice using those models. Ultimately this allows you to become certified in using these specific counseling techniques. Often you will need specific training, usually on the job, as well, while following your degree to completion.

Doctoral level programs as we see in slide seventeen are significantly different than master's level and other programs. Here you get significantly more training in counseling techniques. Not only do you know the theoretical aspects of the models but you know how to use them appropriately, and you have been supervised using them for at least for one to two years in your clinical program or counseling program you have taken. Following your degree you also need to do is a year long internship where you are supervised using the models and given feedback. You may also need to take one to two years following that before for licensure. Many programs also require that an individual takes the national exam after they complete the trainings Even if you may need additional training in specific areas.

The point is, and as we can see in slide eighteen, when you are looking at the different levels, Bachelors level counselors and less have significantly less training, knowledge, and skill sets than masters level counselors. Doctoral level counselors have even more training and college than master’s level students. Despite all the knowledge that both groups and all these groups may have all of them may have minimal knowledge about addictions and some of these groups have no knowledge at all. That may include individuals at the Doctoral level. So, Doctoral level folks may have a lot of knowledge using a wide variety of techniques but they may have minimal knowledge about addictions in relation to helping clients.

Now the flip side of the training issue is important as well. As we can see in slide nineteen, just because one has a lot of experience in a particular aspect of something does not mean one is well trained in working with clients that have a problem in that area. For example, an individual can have been an addict for a long time however that experience does not provide the training or knowledge about how to apply therapeutic techniques to help others. These individuals may help some people, but they may inhibit or even harm other individuals. So one must be very, very careful if one does not have any kind of training at all when working with particular kinds of clients, especially in a treatment setting.

As we can see in slide twenty, there are a wide variety of different treatment models. Basically, they have been categorized into are the sections we have kind of followed along to in the past, such as, biological, psychological and other types of models that are out there as well.

As we can see here we have a variety of biological models and a wide variety of psychological models which continue on slide twenty-one.

And we have a wide variety of other models including sociological models which include economic and enforcement models. And we have family systems models and twelve step models. So there is a wide variety of different approaches one uses in approaching substance abuse treatments.

However, when one is looking at the different treatment models there are some variables that come into play. As we can see in slide twenty-three, the cost to do this is very, very important. Managed care has basically tried to reduce a lot of the cost. In the old days we put everybody in the inpatient treatment. Of course that was very, very expensive. With managed care we have found we can use a lot of outpatient technologies and treatment models to help the clients to get the same success we did with inpatient care. There are other types of issues as well, including the quality of care that one is getting. Who provides the treatment? Should they only be addictions counselors, department of corrections counselors, physicians, clergy, etc? So who provides the treatment becomes a big "turf battle" in many aspects.

Now there is a wide variety of components when looking at comprehensive drug addiction treatment.

What you have to understand and is shown in slide twenty-five, the treatment models or treatments must match the treatment needs of the patient. No single treatment is appropriate for everyone. So what you have to do is use different aspects of different models to help particular clients etc. In addition to that, as you provide substance abuse treatment you need to attend to all the needs of the user and those needs could be considerable, including medical needs because the person has hepatitis, legal needs because the person has a DUI, social needs because the person is homeless, vocational needs because the person has no skill sets for a job, etc. So lots and lots of different things need to be considered when one is looking at treatment.

There is also a wide variety different treatment choices that one needs to examine and utilize when one is trying to develop some kind of program for a person with an addiction. A lot of these choices are shown in slide twenty-six. As you can see the individual begins with some sort of intake or processing or an assessment. Then a treatment plan is made and from that treatment plan all these other aspects may become important. The person might need some kind of self help, they might need some pharmaco-therapy, they may need some case management, and on and on and on. On the outside are a wide variety of different services that one may need to incorporate within your type of treatment program to help this particular client.

The treatment duration, need, and issues associated with that are very, very important. Some of these aspects are shown in slide twenty-seven. The treatment is ultimately going to depend on the patients needs. That is, how much are they using? What is their level of abuse? What treatment models are we going to incorporate to help this client? To do this we use the ASAM criteria. The treatment may only need to be educational and this may be for an individual with a minor possession. Or, may need some intensive care settings in a hospital and around the clock monitoring because the person might be going into DT's, having cardiac arrhythmias, etc. So again, the duration and the type of treatment is going to be very important and will have an impact in relation to cost.

The duration of treatment is also important. As we can see in slide twenty-eight, the duration of the treatment is going to depend on the patient’s problems and needs. Generally, however, any treatment program that is less than ninety days is very limited and has minimal effectiveness in helping clients whether inpatient or in some kind of outpatient setting. What we have found in the research is that you need a minimum of ninety days working with a particular client to have some kind of success. You also need to have a minimum of twelve months if you are going to be using some kind of methadone maintenance to get the client into some kind of treatment compliance and stability. Often times, however, you need to have a longer treatment to help a particular client.

There are other issues that are important. One of these is shown in slide twenty-nine. That is, motivation to enter and to sustain the treatment. In the past we have always believed that for treatment to be effective the person had to come in and they had to basically be ready to get into treatment. What the research has shown is that it is not necessarily the case. Effective treatment does not need to be voluntary. Sanctions and enticements either by the family, by the employer, or by the criminal justice system, can significantly increase entry into treatment and can greatly increase treatment retention. Basically, the outcomes are very, very similar for individuals who enter treatment under legal pressure versus voluntary pressure. This is the reason Drug Court has been having such an impact.

A second aspect relates to medical detoxification. As we see in slide thirty, detoxification safely manages the physical withdrawal from a particular drug. However, it is only the first stage of addiction treatment. If one only does deter, you basically have minimal long-term changes. Often time’s individuals who are in the homeless community enter detoxification centers when it gets very, very cold because it's warm and they get lots of food to eat, etc.

There is also a wide variety of therapy techniques that one needs to consider when one is doing addictions treatment. I have listed some of these in slide thirty-one. As you can see they are quite broad and involve a wide variety of theoretical perspectives.

You may in your addictions treatment involve outside groups including probation/parole. These individuals can have a huge impact in your treatment success. Probation/parole can provide a club and this can allow the person to stay in treatment and stay clean while you are working on other aspects of the persons life. The Department of Health and Welfare also has a wide variety of services to help individuals in substance abuse treatment and these include child and family services. For some individuals this may mean taking children away if they are using and if they are a danger to their children. The Department of Health can also provide a wide variety of services including testing for HIV and STD's and a variety of other things. Job service agencies are also very important, if a person does not have a job, a job service agency can help with that. Other counselors such as in the Mental Health community, religious community, or even the psychological community can also be beneficial when working with substance abuse clients.

Of course, Self Help Groups, as we can see in slide thirty-three can also have a major role. As we can see here there are many types, however, self help groups are not treatment groups. They can help the individual stop using but are best when combined with other treatment models. Self-helps can be very effective if they are run very well and if people are doing what they are supposed to be doing. However, self help groups can also be very problematic if they are not done well.

Another major issue that is occurring and also needs to be examined when you are doing substance abuse treatment are STD's or what are called the blood Bourne pathogens. These are a major problem, and blood Bourne pathogens and often are spread through the use of intravenous devices. Basically, individuals that are IDU's often give some kind of disease and then spread it to their spouse and then to others. This is the major route of spread of a variety of these diseases into the heterosexual population in the United States. It is also a crisis in the Far East, Eastern Europe and in Russia. You need to remember that despite of what everyone says about all the drugs that one can use, there is no cure for HIV and many of the drugs that we are using for HIV are becoming ineffective. Hepatitis C is also becoming a problem as well.

In general, as we see in slide thirty-five, drug treatment is also disease prevention. Basically, drug treatment will reduce the likelihood of getting HIV by six fold in IDU's. Drug treatment also provides opportunities for screening, counseling, and referral in relation to being tested for HIV and other types of diseases.

Now as we see in slide thirty-six, in the past testing for blood Bourne testing was optional and we only did it if the person really wanted it. Today, however, if the individual is an IDU, it is not an option. You need to get the client tested. Over forty percent of the individuals with HIV do not even know they have it and consequently, if they do not know they have it they are spreading it to other individuals. Also if your client is engaging in other high-risk behaviors they also should be tested for using and blood Bourne pathogens as well.

Air Bourne Pathogens are a different group and as we can see in slide thirty-seven, if you suspect a person as having tuberculosis, influenza or other Air Bourne Pathogens you also need to get them tested as well. You can also do both of these at any kind of public health agency.

We have talked about a variety of different types of issues that are associated with treatment. What about the effectiveness of treatment? As we can see in slide thirty-eight, basically, the goal of treatment is to get them back to some kind of productive functioning in society. Treatment reduces drug use by forty to sixty percent and treatment reduces crime by forty to sixty percent as well, and increases employment prospects. Drug treatment can also be as successful as treatment of diabetes, asthma, and hypertension. Drug creates can also be very, very effective when you are doing active monitoring of the person out there as well.

Ultimately, of course, by having an effective drug treatment you basically have impacts in society. Treatment, for example, in looking at taxes and as shown in slide thirty-nine, is less expensive than not treating or incarceration. For example, an individual getting one year of methadone maintenance costs about forty-seven hundred dollars versus an individual being imprisoned which costs between eighteen to twenty thousand dollars per year. Every dollar invested in treatment yields up to a seven dollar reduced crime related cost. That can even increase to twelve to one when you throw in health issues as well. You also, of course, get reduced interpersonal conflicts, better workplace productivity, fewer drug related accidents and on and on and on.

So in general, as we can see here in slide forty, substance abuse and dependence can cause lots and lots of problems and treatment can be very effective in stopping the use.

There are also, as we see in slide forty-one, lots of different types of models and there are a lot of different variables to consider when using a model. And, they also need to be cost effective as well.

So that concludes this section on the overview of treatment models and treatment issues that go along with substance abuse treatment. In our next section we will be talking about specific types of treatment. So until then we hope you are enjoying your day and we look forward to talking with you soon.

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