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Term Paper Residential Drug Treatment vs. Outpatient Drug Treatment Conestoga College Instructor: Mr. D. Dutta By: Mark K. Hollings 6811822

RESIDENTIAL VS. OUTPATIENT Introduction What is drug addiction


Possible stats Diagnostic criteria-addictions Effects of Drug Addiction Treatment Approaches Residential description CRITIQUE Why is it working What’s missing How to improve Conclusion

RESIDENTIAL VS. OUTPATIENT Introduction Addictions to substances have been a serious issue that has impacted many people, their families and the community at large. From consequences that are a mere nuisance to those which can compromise a family finances to problems with parenting to serious health effects including death, addictions represent a chronic and all-encompassing set of conditions attracting attention from politicians, social policy advocates, services providers and families. Addictions to drugs have seen increased complexity and nuance because of the mix of the older drugs with the newer, more manufactured substances. At the same time, the field of addiction has moved from judging the addict as sinful to one who is ill to one who has destiny over their lives. The purpose of this paper is to explore the differences to treating drug addiction and their effects. First, the paper will introduce some brief history of drugs and its relationship to addiction. Second, the paper will summarize the primary effects of being addicted to drugs. Third, the paper will examine common treatment approaches. Finally, this paper will assert that a combination of residential and outpatient modalities provides the best possible outcome for those who struggle with addictions.




Review of the Literature Drug Addiction There has been great debate over what constitutes addiction. Doctors and clinicians argue at length while revising the Diagnostic and Statistical Manual of Mental Disorders, (DSMIV) on whether to use the word addiction, or the word dependence when describing and classifying drug seeking behavior (O’Brien, Volkow, & Li, 2006). The word “dependence” won by a single vote and since then clinicians and doctors has been confusing drug addiction and drug dependence, often leaving those in need of opiate based medication to suffer. Dependence is naturally occurring with repeated doses of a medication such as a narcotic and doctors often confuse this with addiction which causes the physician to cease the medication given to the patient (O’Brien, Vollkow, & Li, 2006). There has since been changes to what classifies as drug addiction in the DSM-V which have been discussed in various other publications (Grohl, 2013). There is now a specific criteria and system that allows physicians and psychiatrists to be able to properly diagnose a person with addiction, substance related disorders and alcoholism. Addiction is essentially any reinforcing behavior that is potentially addicting. (Walters, Gilbert, 2001) There seems to be vagueness to these definitions which can block concerted efforts to research the concept of addiction. (Gori, 1996) Drug addiction is a social issue worldwide and many efforts to understand and explain this mental disorder have been made. To properly explain addiction we must first explore what constitutes as a drug.

RESIDENTIAL VS. OUTPATIENT The Food, Drug and Cosmetic Act indicate that, a substance other than food intended to affect the structure or function of the body is one definition of a drug. Another definition in the Food, Drug and Cosmetic act is: something and most likely an illegal substance that causes addiction, habituation or a distinct change in consciousness. The United Nations Drug Control Programme (UNDCP) published The World Drug Report in 1997 which offers textbook definitions of all facets of drugs and their use from a global perspective. There are four forms of drug use: ritual/cultural, medicinal/therapeutic, social/recreational and occupational/functional. (UNDCP, 1997) There are varying opinions on what classifies a drug and what does not. There are two separate categories according to the World Health Organization, (WHO) substances and drugs, alcohol and nicotine are considered substances, not drugs. (Room, Rosenqvist, 2001) Diagnostic Criteria Addiction to alcohol or specific substances such as: heroin, cocaine and marijuana are characterized by a maladaptive pattern of alcohol or substance use, leading to clinically significant impairment or distress, as manifested 3 or more of the following, occurring any time in the same twelve month period: Tolerance, which is the need for more of a drug or substance to achieve the same effect or the diminished effect with repeated use of the same amount of a substance or drug. Withdrawal, which can develop within hours to days of cessation from drug use; symptoms range from and can include: anxiety, agitation, delirium tremens, flu-like sickness and grand mal seizures. The substance is taken in greater amounts of for a longer period of time than was intended. There is an ongoing desire or unsuccessful efforts to control, moderate and cut down on substance intake. The getting, using, and finding


RESIDENTIAL VS. OUTPATIENT ways and means to get more is taking all of the person’s time. Important social and occupational activities are substituted for alcohol or substance use. The user continues use regardless of detrimental effects that he or she is made aware of and can exacerbate the problem. An example of this would be a person continues to drink even though he or she has an ulcer and ingesting alcohol could kill that person (Compton, Dawson, Goldstein, & Grant, 2013). There is also something known as the Addiction Severity Index, (McLellan, Carise, Coyne, & Jackson, 2013) which is more of an interview than a test. This is used by treatment professionals to measure the severity of a client’s addiction issues, which will be discussed during the treatment phase of this paper.


Effects of Drug Addiction The effects of drug addiction range in type and severity. It is well known that drug addiction has emotional and social consequences, but for the purpose of this paper, the medical repercussions are the ones that will be discussed. There has been extensive research done on how the brain reacts to drug addiction. Profound changes to the brain take place in the early stages of addiction which cause a person to be vulnerable to relapse long after cessation of taking the drug. (Koob, Le Moal, 2000) Drug addiction is the end result of a progressive illness that begins with casual ingestion of a substance. A drug is voluntarily taken because of its reinforcing and hedonic effect; the user loses control over this behavior and habitually takes the drug. The next phase is compulsion, a need for the drug despite the consequences. The process from voluntarily taking a drug to compulsively taking a drug is due

RESIDENTIAL VS. OUTPATIENT to these chemical changes in the brain. (Everitt, Robbins, 2005) It has long been thought that drug addiction was a result of poor choices made by the affected person. Scientists now believe that the effects of drug addiction on the brain may undermine voluntary control of the user, this combined with environmental and developmental factors can leave certain individuals predisposed to drug addiction (Volkow, Li, 2004). The position of many physicians and scientists is that drug addiction is not a social problem, but a health problem and therefore should be treated in the same manner as any other chronic illness. (McLellan, Lewis, O’Brien, Kleber, 2000) Treatment Approaches There are many treatment approaches for addiction. They range from abstinence based treatment to drug replacement therapy such as methadone. There are residential treatment centers and community-based outpatient treatment facilities. A wide variety of treatments from cognitive behavioral therapy to electro-shock therapy has been tried in the quest to cure drug addiction. The two main ways to treat drug addiction are: residential treatment, and community-based treatment. Community-based treatment consists of a support group, or one on one counselling done in the community. There are multiple treatment models that can vary from place to place. Scientist and treatment professionals alike use these models to understand craving, drug seeking behavior and withdrawal. Understanding craving and how drug intake reacts like a positive reinforcement in the brain and withdrawal from a drug is a negative reinforcement can allow clinicians to better understand how to treat clients (Wise, Roy, 1988). Treatment modes


RESIDENTIAL VS. OUTPATIENT and beliefs about how to effectively treat addiction are consistently being updated and revised. There is a framework that suggests that the relationship between patient attributes and program attributes can lead to program participation and a therapeutic relationship in early engagement. These can then to psycho-social change and behavior changes in early recovery, which then can lead to sufficient retention in stabilized recovery, leading to positive post treatment outcomes with the right support network (Simpson, 2004). A treatment model that is also widely used is Meaning Centered Therapy (MCT). MCT was developed by Paul Wong, who had the idea that addiction was the result of living a life with little meaning. MCT combines several different types of psychological approaches which include: cognitivebehavioral, psychoeducational, narrative and positive psychologies. MCT is basically a positive existential form of psychotherapy (Thompson, 2012) Many outpatient and residential treatment programs utilize the twelve step method of treatment which was first introduced in 1939 by Bill Wilson. Bill Wilson was one of the founding members of Alcoholics Anonymous, a support group designed by alcoholics for alcoholics. It is a process that begins with the admission of a substance abuse problem, and also employs spiritual aspects and peer support. There is a belief that the therapeutic value of one alcoholic/addict helping another is without parallel, and that one addict/alcoholic can best understand another addict/alcoholic (Wilson, 2001). There is also a firm belief in service to new members by older members, stating that a member can only keep and maintain their sobriety by passing on the knowledge and spiritual principles given to them so freely by other members. This builds a sense of inclusion and community amongst members (Wilson, 2001).




Residential Treatment Description Residential treatment is a facility based treatment. Clients are placed in an institution for a period of time and are required to complete a specific number of weeks or months of treatment. Whereas outpatient treatment is individualized and fluid, residential treatment is more rigid and structured. There are two ways in which a person will be admitted to a residential drug treatment program, voluntarily and coercion. One of the most widely used methods of evaluating whether or not someone needs residential treatment is the Addiction Severity Index (ASI). The ASI has been in existence for over twenty years and has been translated into several different languages for use worldwide (Makela, 2004). The ASI focusses on the client’s seven problematic areas: physical health, employment and financial support, family and social relationships, illegal or criminal activities, psychiatric symptoms and drug and alcohol use (Grissom, & Bragg, 1991). Upon the completion of this test the interviewer can make a recommendation that the client seek residential treatment. The other way a person can enter a residential treatment facility is through coercion. This can include a means of parole from a prison or other criminal institution, or it can be by order of a judge in a drug court or criminal proceeding. It isn’t legal to order someone into treatment, so the offender is given an option to either go into treatment, or serve their time out in prison. This is also referred to as compulsory drug treatment which creates more of a balance between punishment and rehabilitation (Fischer, Roberts, & Kirst, 2002). The practice of compulsory or coerced treatment has been widely criticized, but recent studies have found

RESIDENTIAL VS. OUTPATIENT to have good result in both client retention and short term treatment responses. There has also been a link between lower recidivism rates for crime in those clients who chose treatment over prison (Urbanoski, 2010). Critique What Works There seems to be several different approaches that are in place and are effective. They range from outpatient treatment, methadone maintenance and residential treatment programs. Due to lack of long term follow up interviews and the validity of self-disclosure when dealing with addict/alcoholics, it is impossible to know just how effective each treatment is. There seems to be a consensus amongst treatment professionals that early intervention yields the best results (Schtz, Aub Linden, Torchella, Li, Al-Desouka, & Krausz, 2013). A theme that seems to run in both residential and outpatient treatment facilities is the twelve step model introduced by Bill Wilson and the organization Alcoholics Anonymous (A.A.). There has been many different groups formed that use this model: Narcotics Anonymous (N.A.), Cocaine Anonymous (C.A.) and many other groups. Most treatment facilities also adhere to the twelve step model as well for many reasons; it encompasses accountability, amends, self-care and spiritual aspects, as well as providing a solid support network for residential clients upon release. Supports provided by N.A. and A.A. include: sponsorship (a mentor who is a senior member), a multitude of literature and daily readings, as well as regular support group meetings. The twelve step model seems to be the only program that boasts long term sobriety for its members. In fact, in pages 83-84 the Alcoholics Anonymous handbook, or what


RESIDENTIAL VS. OUTPATIENT members call The Big Book, Bill Wilson makes the claim that through working their program anyone can lose their desire to abuse substances for life (Wilson, 2001). Due to the fact that the twelve step model is used in all forms of treatment and has millions of members attending meetings worldwide, it is safe to say that this form of treatment is effective. What Is Missing There are many glaring deficiencies in treating addiction. Due to the fact that long term follow up with clients is difficult and self-report is fallible, it seems impossible to know the validity of treatment approaches. Some residential treatment facilities give percentages of success yet many of these facilities of motivated by profit, so reliable statistics are hard to come by. There is substantial evidence that early intervention and even coerced treatment can be effective (Shtz, et al, 2013), but there is not a system in place that makes someone suffering from the disease of addiction seek treatment. Drug courts simply give a person the option of taking treatment over prison time, it is not mandatory. There is also the issue of waiting lists for treatment, as well as waiting lists to receive assessments such as the Addiction Severity Index (Grissom, & Bragg, 1991). The long period of time for treatment assessment can lead clients to have a change of heart, or die from their disease. There are however, some minor changes that can occur to make treatment of the disease of addiction more effective. How to Improve Over the last one hundred years the treatment of addiction has made great progress. Gone are the days of committing addicts and alcoholics to mental institutions for the remainder of their lives (Wilson, 2001). As research and development of addiction treatment improves, so


RESIDENTIAL VS. OUTPATIENT does the prognosis of those who still suffer from this disease. Due to the research results that indicate that coerced residential treatment is effective, (Shtz, et al, 2013) then mandatory residential treatment made by drug courts and even family members can yield the same results. It is well documented that many treatment facilities have waiting lists for entry and even assessments. By employing outreach workers to act in the same manner as a sponsor would in a twelve step model, the client would have a person who empathizes and can show him or her where meetings are taking place, as well as other treatment options while they await admission to their facilities. This would drastically reduce the likelihood of a change of heart or untimely overdose. The burden of finding appropriate support networks before and after residential treatment has been with the client, and acts as a deterrent to seeking out these support networks. By providing an outreach worker for clients, a treatment facility can ensure that the client is receiving adequate care both before and after leaving the facility. The outreach worker can also make a clear point that long term recovery does not happen in ninety days at a treatment centre, but requires a combination of outpatient, residential and twelve step treatment. By combining residential, outpatient and twelve step treatment, clients greatly increase their chance at long term recovery from the disease of addiction. According to The Basic Text (2008) of Narcotics Anonymous, addiction is a disease with no known cure, but it can be brought into remission and recovery is then possible. Conclusion Addiction, like poverty or homelessness, is a social issue that is neither static nor absolute. Those looking for black and white answers to questions posed by addiction will be left scratching their heads. Further and ongoing studies in the field of addiction yield new results


RESIDENTIAL VS. OUTPATIENT on a regular basis. What was an acceptable practice twenty years ago seem antiquated, and quite often dismissed by practitioners in the field today. Addiction has many consequences, not only for the affected individual, but their families, the health care system, as well as the legal system. Due to the growing population of addicted people, it is a field of study that will be explored in great detail in the future. There is not a single cell that can be isolated and cured; addiction affects behavioral, psychological and physical components of a human being. Therefore, the only approach that will address this disease is a multi-faceted one, combining outpatient, residential, and twelve step treatments, which will adequately address all three affected portions of the patient.