Thursday, July 17, 2014

Chapter 5 Treating Substance Use Disorders

In This Chapter

Substance use disorders (SUDs), like other chronic diseases, are treatable. Trained SUD treatment providers can determine the best treatment path for individuals to take and can enlist the assistance of other service providers, such as child protective services (CPS) caseworkers, in the treatment process. This chapter discusses the goal of SUD treatment, important treatment considerations, various approaches to treatment, issues related to gender sensitive treatment, and barriers that may impede individuals from receiving treatment. This chapter is intended to help CPS caseworkers strengthen their understanding of treatment services available to help the families with whom they work. The role of CPS in supporting the treatment process is discussed in more detail in Chapter 6, The Role of Child Protective Services When Substance Use Disorders Are Identified.

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The Goal of Treatment

An SUD is a medical condition with significant behavioral effects. These behaviors may frustrate, stymie, and anger treatment providers and CPS caseworkers. While individual experiences vary, persons with an SUD often have:

  • Little experience or skills with which to cope with their feelings. Their substance use tends to numb discomfort, at least temporarily. Many of these individuals have been turning to drugs and alcohol since their teenage years.
  • Difficulty escaping or solving everyday problems without using substances. As a result, they can feel quite helpless when confronted with the day-to-day challenges of life.
  • Poor communication skills. They may be ineffective in some areas and over-emote in others.
  • Problematic behaviors, such as being manipulative or dishonest. These behaviors may be useful, however, in helping them obtain drugs and alcohol or hiding the use of these substances. Some individuals with SUDs may find it easy to be dishonest because they have buried or avoided their true feelings.

The goal of treatment is to help individuals break the cycle of addiction and dependence so that they may learn better ways of dealing with challenges in their lives. Caseworkers should keep in mind that treatment does not equal recovery. Recovery is a lifelong process, with treatment being one of the first steps. Recovery entails making lifestyle changes to regain control of one's life and accepting responsibility for one's own behavior.90

Research has demonstrated that SUD treatment works. A number of national studies over the past decades have shown that SUD treatment can result in abstinence from substance use, significant reduction in the abuse of substances, decreased criminal activity, and increased employment.91 Recent studies also link SUD treatment for mothers with children in substitute care to improved child welfare outcomes, such as shorter stays in foster care for children and increased likelihood of reunification.92 Furthermore, treatment has been shown to be cost-effective and to reduce costs in such areas as crime, health care, and unemployment.93

Detoxification

Some individuals require detoxification services before they are able to participate effectively in ongoing treatment and recovery. Detoxification is a process whereby individuals are withdrawn from alcohol and drugs, typically under the care of medical staff; it is designed to treat the acute physiological effects of ceasing the use of substances. It can be a period of physical and psychological readjustment that allows the individuals to participate in ensuing treatment. Medications are available to assist in detoxification. In some cases, particularly for alcohol, barbiturates, and other sedatives, detoxification may be a medical necessity, and untreated withdrawal may be medically dangerous or even fatal.

The immediate goals of detoxification programs are:

  • To provide a safe withdrawal from the substance of dependence and enable individuals to become alcohol- or drug-free. Numerous risks are associated with withdrawal, ranging from physical discomfort and emotional distress to death. The specific risks are affected by the substance on which the individual is dependent.
  • To provide withdrawal that protects people's dignity. A concerned and supportive environment, sensitivity to cultural issues, confidentiality, and appropriate detoxification medication, if needed, are important to individuals maintaining their dignity through an often difficult process.
  • To prepare individuals for ongoing alcohol and drug abuse treatment. While in the detoxification program, individuals may establish therapeutic relationships with staff or other patients that help them to become aware of treatment options and alternatives to their current lifestyle. It can be an opportunity to provide information and motivate them for treatment.

Detoxification is not needed by all individuals and is not intended to address the psychological, social, and behavioral problems associated with addiction. Without subsequent and appropriate treatment, detoxification rarely will have a lasting impact on individuals' substance-abusing behavior. The appropriate level of care following detoxification is a clinical decision based on the individual's needs.94

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Treatment Considerations

SUD treatment is not a "one size fits all" service or one that remains static over time for a particular participant. For example, an individual who drank heavily for 10 years and is mentally ill is likely to have different treatment needs than an individual who recently became addicted to cocaine. When treatment is provided, the following should be considered:

  • Type and setting. An individual should be placed in the type and setting of treatment that is most appropriate for the specific problems and needs. Just as a doctor may determine that a patient should receive medication instead of surgery to correct a problem, an SUD treatment provider must make decisions about the most appropriate course of treatment for an individual. The type, length, and duration of the treatment vary depending on the type and the duration of the SUD and the individual's support system and personal characteristics. The duration of the treatment may range from weeks or months to years.
  • Reassessment and modification of treatment plan. An individual's treatment and service plan should be reassessed and continually modified to ensure that the plan meets the person's evolving needs.95
  • Involuntary treatment. An individual does not have to "hit bottom" or "want to change" in order to benefit from treatment. Involuntary or mandated treatment can be just as effective as voluntary treatment. Sanctions or enticements in the family, work, or court setting can significantly increase treatment entry, retention, and success.96
  • Attorney involvement. In instances where the parent has an attorney, the attorney also can play a key role in the early engagement of the client in treatment. CPS caseworkers and SUD treatment providers can facilitate this by reaching out to attorneys to help them understand the treatment process and clients' needs. This helps them represent the clients better and provides a better opportunity for reunification.
  • Timetables. Because of the potential conflicts between child welfare and treatment timetables, treatment should begin as soon as possible so that there is time for family reunification. Often, however, there are delays in treatment either because it is not available or the need for treatment is not determined right away. CPS caseworkers and SUD treatment providers should work together to engage clients in treatment as early as possible.

Timetables in Child Welfare and Substance Use Disorder Treatment

CPS agencies and SUD treatment providers have their own timetables for establishing family and individual well-being. The Adoption and Safe Families Act (P.L. 105-89) requires CPS agencies to:

  • Establish a permanency plan within 12 months of a child entering the child welfare system
  • Initiate proceedings to terminate parental rights if a child has been in foster care for 15 of the most recent 22 months.

SUD treatment can range from weeks or months to years. CPS caseworkers and treatment providers, therefore, should communicate frequently to make sure that this time is productive and to serve the children and families most effectively.97

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Common Treatment Approaches

There are a number of ways to categorize treatment, based on the level of care (i.e., intensity of treatment and services offered) or the theoretical orientation and treatment approach. The following are some common treatment approaches:

  • Cognitive-behavioral approaches address ways of thinking and behaving. Cognitive-behavioral treatment helps participants recognize situations in which they are most likely to use drugs, develop strategies for dealing with these situations, and build specific skills to address behaviors and problems that are associated with SUDs. For example, if a woman suggests that she is most likely to use cocaine after she has had a fight with her partner, the therapist would work with her to develop more positive ways of dealing with her anger and frustration following a fight. The treatment provider also may detail possible consequences to the individual, such as breaking parole and being forced to return to prison, as a means of changing behavior.
  • Motivational enhancement treatment incorporates some elements of cognitive-behavioral treatment, but focuses on increasing and then maintaining participants' motivations for change. Rather than forcing individuals to accept that they have a problem, this approach focuses on the individual's needs and the discrepancies between their goals and their current behaviors. This approach seeks to draw solutions from the treatment participants rather than having the solutions imposed by therapists.
  • Contingency management includes both motivational enhancement treatment and an additional component of reinforcements and rewards. For example, credits may be offered as a reward for established positive behaviors, such as consistent attendance in group therapy or negative urinalysis testing. These credits then can be exchanged for items (such as baby products).
  • Therapeutic community is an approach based on both cognitive-behavioral therapy and on the notion that treatment is best provided within the context of a community of individuals who have similar histories. This model was developed to provide treatment to individuals with antisocial character traits in addition to SUDs and tends to be highly confrontational. By having treatment participants confront each others' behaviors and attitudes, they learn a great deal about their own behaviors and also learn from the other participants. Often, therapeutic community models of treatment are found within the correctional system. Given its confrontational nature, a therapeutic community may not be appropriate for some individuals. For example, women who have experienced intimate partner violence likely would not react well to this treatment approach.
  • Trauma-informed treatment services generally follow one or more of the above treatment theories and reflect an understanding of trauma and its impact on SUDs and recovery. This approach acknowledges that a large percentage of SUD treatment participants have sustained physical, emotional, and sexual trauma in their lives and their disorder may be the result of self-medicating behaviors to deal with post-traumatic stress disorder symptoms.
  • Trauma-specific treatment services go a step further than trauma-informed treatment services and address the impact of the specific trauma on the lives of participants. This approach works to facilitate trauma healing and recovery as part of the treatment services. Several integrated, trauma-specific, treatment models for women have been developed in recent years.98
  • Treatment based upon the relational model of women's development acknowledges the primacy of relationships in the lives of women and focuses upon the establishment and support of positive relationships. These positive relationships for the treatment participant may be with the therapist or with other significant figures, especially children and spouses.

Model Treatment and Prevention Programs

The following Internet resources provide information about model SUD treatment and prevention interventions and their characteristics:

  • The Substance Abuse and Mental Health Services Administration (SAMHSA) has compiled a list of evidenced-based programs that have prevented or reduced SUDs and other related behaviors. SAMHSA's National Registry of Evidence-based Programs and Practices has reviewed these programs rigorously and assessed their effectiveness. To view this list, go to http://modelprograms.samhsa.gov.
  • SAMHSA's Guide to Evidence-Based Practices provides listings for more than 35 websites that contain information and research on specific evidence-based programs and practices for the treatment or prevention of SUDs. Listings can be sorted and browsed by topic areas, target age groups, and settings. To view these listings, visit http://www.samhsa.gov/ebpWebguide/index.asp.
  • The National Institute on Drug Abuse of the National Institutes of Health offers a list of principles for substance use prevention based on a number of long-term research studies. That list can be viewed at http://www.nida.nih.gov/Infofacts/lessons.html.

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Support Services

Along with SUD treatment, supplemental services often are provided to give additional support aimed at improving treatment outcomes. The following are important support services for treatment:

  • Case management services are aimed at eliminating or reducing barriers to participation in treatment and include links to housing, food, medical care, financial assistance, and legal services. Case management also may include problem-solving sessions to assist individuals in establishing priorities among the many demands made upon them by multiple systems.
  • Twelve-step models that incorporate the 12-steps of Alcoholics Anonymous into treatment. Participants "work the steps" and move through treatment by accomplishing each of the 12-steps with guidance from a sponsor and with emphasis on attendance at meetings. Spirituality or belief in a "higher power" is a central component of 12-step models.
  • Recovery mentor or advocate programs pair a person in recovery with individuals in need of treatment to support their engagement and retention in the process. Recovery mentors or advocates offer the unique perspective of having been through a similar experience and can offer the client insight to matters that CPS caseworkers and SUD treatment providers cannot.
  • Abstinence monitoring includes urinalysis testing, breath testing for alcohol, and the use of the sweat patch and other technologies. This can be an important component of treatment as it provides opportunities for feedback to individuals who are working to change addictive behavior. Negative drug test results can be used for reinforcement of changed behavior, while positive test results can be a cue to the treatment participant and therapist that the treatment plan may need adjusting.

There also are numerous other support services (e.g., mental health counseling, medical care, employment services, child care) that may be provided to assist families.

Treatment Example: Methadone Maintenance

Treatment can take many forms and can be multilayered and complex in attempting to address the nature of SUDs. For example, opioid replacement therapy is a treatment that substitutes a noneuphoria inducing and legally obtainable drug (e.g., methadone, buprenorphine) for heroin or another opiate. The treatment also provides counseling and other rehabilitation services. Methadone maintenance treatment is a type of opioid replacement therapy and is very effective. Along with preventing illicit opiate use, methadone has been shown to be effective in reducing criminal activity and increasing employment. Additionally, this treatment method reduces the risk of HIV-associated behaviors (e.g., needle use and sharing) and infection.99

Individuals engaged in methadone maintenance treatment can face heavy discrimination within the child welfare system from judges, attorneys, and caseworkers who believe the ultimate goal of treatment should be a completely drug-free individual. Stopping the methadone treatment, however, leaves the individual at a very high risk for relapse to illicit opiate use and its associated high-risk factors, including unsafe injection practices and illegal behavior in order to support a habit. All of these can significantly increase the risk of abuse or neglect to children in the custody of these parents. Hence, the decision to require a detoxification from methadone must be considered carefully and based upon sound clinical principles rather than upon the stigma associated with methadone treatment.

TANF and Substance Use Disorder Treatment

In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) fostered a new vision for public assistance. PRWORA established the Temporary Assistance for Needy Families (TANF) block grant, which treats welfare as short-term, time-limited assistance designed to help families move to work and self-sufficiency. Its work requirements and time limits allow little room for work exemption and, therefore, created an incentive for agencies to examine the needs of those recipients overcoming serious and more difficult challenges, such as SUDs.100 National estimates of the welfare population who have substance abuse issues range from 16 to 37 percent.101 The 2007 National Survey on Drug Use and Health (NSDUH) reports a rate of 8.0 percent for illicit drug use in the general population.102

Both TANF and substance abuse treatment program administrators recognize that treatment in the absence of work does not fully meet the needs of TANF clients with substance abuse issues.103 Instead, TANF clients should receive treatment while concurrently pursuing work and work-related activities related to self-sufficiency.104

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Gender-Sensitive Treatment

Historically, SUD treatment has been focused on men, and fewer women had access to treatment services. In recent years, however, additional emphasis and funding have begun to address women's specific needs.105

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Women

The ability to access and to remain in treatment can be difficult for anyone. Motivation, transportation, insurance coverage, and waiting lists all can impede an individual's attempts at recovery. Women, however, often face additional challenges when seeking treatment.

Both men and woman can have significant others who have SUDs. However, women with partners with SUDs are more likely to abuse substances themselves.106 For instance, some women have partners with SUDs and face the loss of these relationships when they make the decision to seek help. These partners may discourage women's efforts to obtain treatment. Violence in these relationships is not uncommon. Not only do these women face the loss of a relationship, but many also face the loss of economic support. This has particular importance when the women are also mothers with young, dependent children.

Even if mothers do not have to contend with unsupportive partners, seeking treatment still can be difficult. Many women do not want to enter treatment because they fear their children will be taken away if it is discovered that they have an SUD. Women also may fear the social stigma of being considered a "bad mother" if others find out about their drug use. When women decide to enter treatment, child care frequently is a critical hurdle to overcome. Few residential programs allow children to remain with their mothers while in treatment, and few outpatient programs provide child care, leaving it up to the mothers to identify a safe, reliable place for their children or to pay for licensed child care services.

The profile of women who have SUDs differs from their male counterparts. Compared to men, a greater number of women who enter treatment have a history of physical or sexual abuse.107 Additionally, among persons with AIDS, a greater percentage of females than males were exposed through injection drug use and may participate in risky sexual behavior or trade sex for drugs.108 Additionally, women are more likely than men to have co-occurring mental health problems.109

Women receive the most benefit from treatment when the treatment program provides comprehensive services that meet their basic needs, such as transportation, job counseling and training, legal assistance, parenting training, and family therapy, as well as food, clothing, and shelter. Additionally, research shows that women benefit from a continuing relationship with the SUD treatment provider throughout treatment and that women, during times of lapse or relapse, often need the support of the community and the encouragement of close friends and family.110 For more information on components of women-centered SUD treatment, visit http://www.nida.nih.gov/WHGD/WHGDPub.html.

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Men

Men face many of the same treatment hurdles as women, but while treatment historically has focused on men, there is still relatively little literature that discusses men's roles within the family, particularly how their substance use affects their roles as fathers and partners. Most often, mothers are the focus of CPS cases and are involved in treatment. While some of these women may be reluctant to involve fathers in the treatment process, both parents should be involved whenever possible, provided it does not increase safety risks. In addition, CPS caseworkers usually are required by the court to seek and to involve absent parents. In some cases, it is the fathers of the children in the child welfare system who become the focus of intervention due to the presence of mothers in treatment. In these cases, men's roles as fathers and primary caregivers for their children warrant significant attention as they struggle to provide appropriate, nurturing, and consistent parenting.

Involving Fathers in Case Planning

The importance of involving nonresidential fathers is particularly relevant when the mother is the perpetrator of child maltreatment, and the child has to be removed from the home. Fathers can be a source of support to the mother of their child, both financially and emotionally; are an irreplaceable figure in the lives of their children; and can be a supportive presence as the family deals with the problems that contributed to the maltreatment, especially when the mother is going through SUD treatment. If it is determined that the family is not a safe place for the child, the nonresidential father is a placement option that should be considered.

Of course, there may be times when involving the nonresidential father in the case planning process is impossible or ill-advised, including when the father is involved in illegal activities. More often than not, however, the nonresidential father can play a useful role, although bringing him into the process may require skilled negotiating on the part of the caseworker.

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Barriers to Treatment

Most people who have SUDs do not receive treatment. According to NSDUH, approximately 23.2 million people in 2007 needed SUD treatment. Of these, 2.4 million (10.4 percent) received treatment at a specialty facility (including hospitals, drug or alcohol rehabilitation facilities, and mental health centers), and the remaining 20.8 million did not. Of the individuals who were classified as needing but not receiving treatment, only an estimated 1.3 million reported that they perceived a need for treatment for their problem, and 380,000 reported that they had made an effort to receive treatment.111 Among women of childrearing age (18 to 49 years) who needed treatment in the past year, only 10.4 percent received it, and only 5.5 percent felt they needed it.112

There are multiple and complex barriers to treatment. According to NSDUH, of those individuals who did not receive treatment even after making efforts to obtain it, the most commonly reported reason was because they were unable to afford it or lacked health coverage.113 Other reasons that individuals may not be able to receive, or want to receive, SUD treatment include:

  • Lack of available treatment spaces
  • Not knowing where to go for treatment
  • An ambivalence or fear about changing behavior
  • A belief that they can handle the problem without treatment
  • Concerns about negative opinions among neighbors, community members, or co-workers regarding treatment
  • Relationships with partners and with family members who still may be using substances and who do not support the individual's efforts to change
  • A perception of "giving in" when treatment is mandated by an outside source, such as the court or social services department
  • Co-occurring mental health disorders exacerbated by the individual's attempts at abstinence
  • A lack of transportation to and from treatment
  • Economic difficulties in which the need to work takes priority over the participation in treatment
  • A lack of available child care during treatment times.

CPS caseworkers can help clients who have SUDs identify barriers to participation in treatment and support the development of strategies to overcome these barriers.

https://www.childwelfare.gov/pubs/usermanuals/substanceuse/chapterfive.cfm