The ultimate goal of treatment for an addiction (drug dependence) is to restore the individual’s freedom of choice over their own behavior. This situation automatically results in detachment from the substance that caused the problem while treatment is ongoing.
This effect develops gradually (over months), and does not always or necessarily begin with an interruption of the person’s habitual substance use.
Addiction treatment requires from the person undergoing treatment only the willingness to be treated, the motivation to receive treatment, and acceptance of the patient role (that is, following the physician’s instructions and assessing the results together with the physician). Addiction treatment does not require self-control, which would be absurd, nor moderation, for the same reason, nor does it require achieving abstinence from the outset (although most people with drug dependence are able to detoxify, this is not technically required by most treatments and does not determine the final outcome).
The factors that influence the outcome of effective treatment are, in order of importance and logic:
– the severity of the illness (with reference to its core symptoms) at the time treatment begins
– the specificity of the treatment (that is, the scientific evidence supporting its effect on that particular addiction)
– the availability of ancillary services for associated and related problems (such as infectious, legal, etc. issues)
– the quality of the personal relationship between the physician treating the case and the patient, within their respective roles
The first of these factors presupposes that a diagnosis has been made, and that it has been made among three possible conditions: controlled use (non-pathological, although still toxic depending on the amount used); uncontrolled use during the episode but with the possibility of controlling relapses, beginning with abstinence (so-called abuse); and dependence (or addiction), which entails an inability to control the repetition and course of substance use, both acutely and over time, whether starting from habitual use or from a stable and prolonged state of non-use.
Once the diagnosis has been made, the essential things to know or ask are basically the following:
1 – Which treatments are scientifically valid, and what results do they produce?
Existing treatments that can properly be described as “therapies” are available for various addictions. They are not always effective in the majority of patients or at every stage, even when officially authorized. Conversely, some treatments that can already be proposed scientifically on the basis of research data, and that are based on drugs already on the market, are not officially registered for this indication. The quality of a treatment does not depend on the intentions of the person administering it, on how strongly someone “believes” in it, on whether it is “innovative,” on whether it is based on an anti-drug ideology, or on whether the person feels comfortable in the environment in which it takes place.
A treatment is considered effective when it works in people who lack self-control, do not expect to be able to change for the better, do not start from a favorable personal and social situation, and are mentally altered and impaired by the effects of addiction, particularly in their ability to understand the importance of treatment at the outset and to perceive its possible outcomes as realistic.
Getting the patient to undergo treatment is not always easy, because one cannot expect direct and consistent cooperation at the beginning, even when the person sincerely asks to be treated in order to “get out of it.” In any case, it is pointless to ask the patient, as a starting point, to achieve the very outcome that treatment is supposed to produce. It would be like asking a patient with pneumonia to start breathing normally again before beginning antibiotic treatment.
In sequence, treatment produces: first, a reduction in substance use and in the associated risks; then, a tendency toward cessation of use and normalization of the person’s mental condition; and finally, a recovery of social and productive abilities.
2 – In addition to the core treatment, what does the therapeutic program include to facilitate success, and how should these elements be understood?
Ancillary interventions—for example, access to legal, social, and medical services while treatment for addiction is being established—may improve adherence to medical treatment for addiction, create strong motivation, or even constitute a form of “leverage” (for example, in the case of alternatives to imprisonment). In any event, anything that connects the patient to treatment or encourages engagement with it increases the likelihood that treatment will be implemented in ways and at times that allow it to work as effectively as possible.
Conversely, interventions involving the same actors (physicians, social workers, authorities, parents, friends, partners) that do not encourage the patient toward treatment, but instead urge or admonish them to “change their life” or stay away from substances, lecture them about the benefits of a drug-free life, or simply give them trust and responsibility, have nothing to do with the mechanisms of addiction and do not affect relapse. Although a generally supportive environment may facilitate certain types of intervention (such as detoxification), this does not affect the core of the illness and often simply constitutes a way in which resources (financial, human, and social) are cyclically invested and exhausted amid disappointed expectations and promises that cannot be kept.
3 – Is treatment determined from the beginning, or does it need to change over time?
The therapeutic program provides, especially during the first months, for regular and frequent assessments. These are used to determine certain parameters essential to the functioning of the treatment itself, such as the dosage of a medication. Generally, during the first months, adjustments to the dosage of an anti-addiction medication will tend to be upward, in search of the best achievable balance. If a dose is sufficient from the outset to obtain excellent results, there should be no tendency to reduce it, since doing so would be contrary to the fundamental objective of rehabilitation and relapse prevention. Much more often, starting from doses that are initially sufficient, the dose will be increased in response to the reappearance of symptoms or to renewed, even sporadic, substance use. Toxicological tests (usually urine tests) provide a reliable means of informing this decision, in addition to the medical examination and clinical interview.
Ancillary interventions (for example, employment projects or housing solutions) can sometimes only be considered once the addiction has improved or is under control. They may therefore be introduced at a later stage, so that the sequence follows a logical order: first control of symptoms, followed by initiatives that require controlled and autonomous behavior on the part of the patient.
Substance use during treatment should prompt an adjustment of treatment. Relapse, or simply substance use that occurs with reduced frequency and intensity, is not evidence that treatment has failed, at least not until treatment has been tested for a sufficiently long period and at adequate doses.
4 – How long should treatment continue once it has proved effective and the person has been rehabilitated?
Because addiction is a long-lasting illness that tends to recur periodically, treatment is essentially preventive: it restores a state of balance and therefore, by the same principle, hinders relapse. Discontinuing treatment is always a condition associated with a greater risk of relapse than continuing treatment. Biological recovery from addiction cannot be demonstrated except retrospectively, and should not be presumed on the basis of the patient’s mental state, functioning, or attitude. Well-being is the outcome achieved through treatment, not the prerequisite for deciding to discontinue it. Well-being is the result of treatment followed over the preceding period, not of the most recent treatment; relapse is therefore the risk and consequence of having failed to take preventive treatment during the preceding period.
Relapse in a person who is not receiving any treatment is neither a “new development” nor evidence of a “relapsing case”; it is simply an expression of what the illness normally entails when untreated, namely recurrence. Relapse in a person who is not receiving treatment is not evidence that previous treatment was ineffective; rather, it is a valid reason to resume treatment as soon as possible.
The patient is not dependent on the treatment, still less on the medication being used. What the patient is dependent on is the illness itself, with its tendency to return after an apparent state of well-being. The patient can rely on treatment because it produces effects that do not diminish over time, but remain as long as treatment continues.
5 – What are the most common errors in treatment?
The most common errors are the use of non-therapeutic (low) doses and the premature and rapid discontinuation of treatment. Another common error is the use of non-specific medications in place of specific therapies, with the idea of reducing the latter and using, either continuously or as needed, medications intended for other disorders (e.g., anxiolytics or antidepressants).
A frequent mistake is allowing the patient to decide which dose seems “right” or which dose “covers” them adequately. This is an error because the patient will think in terms of the substance and its effects rather than the medication as a treatment. They will use its short-term properties and judge whether dose changes are appropriate on the basis of immediate results. The consequence is that they remain on low doses, take them inconsistently, and discontinue treatment as soon as possible.
These errors typically result in the person spending years with the unsuccessful idea of stopping treatment and “trying again,” based on personal motivation or on external circumstances that they consider favorable. Instead, with each cycle they relapse into substance use and return to treatment (poorly administered), which they ultimately come to “hate” because they experience it only during the worst periods of the illness, as a sign of failure.
The most common error of all remains therapeutic delay: avoiding treatment until the illness has become very severe, and avoiding effective treatments among the available options in favor of symptomatic interventions (such as detoxification) that do not affect the core of the illness.