Which Treatment Should I Pursue?

by A. Thomas McLellan, Ph.D.

I am not sure I have a substance use problem

Perhaps you have found yourself drinking or using more than you intended, or you have had an accident or social problem associated with your alcohol or drug use, or you have friends or family who have been worried about your use.

Option 1

Try to reduce or quit yourself. Experts have set guidelines that can help you determine if you have a problem. In the case of alcohol, drinking more than four drinks in a day, 14 in a week is considered "heavy drinking" for men. Women who have more than three drinks in a day, 11 in a week fall into this category. If many of your friends drink this much, it may be difficult for you to drink less and still be around them.

Try drink-reducing strategies such as having a drink of water or soda between alcoholic drinks; or taking only the amount of cash that you wish to spend at a bar and not using credit cards. Other strategies include making a contract with yourself for use only at planned days and time periods. The Internet offers many other reduction strategies. Regardless of your strategy, keep the alcohol guidelines in mind - and be honest. If you find you cannot keep within these guidelines it may mean you need additional help.

Option 2

See a physician. Ask about medications to aid in the reduction of drinking. Unfortunately, there are no medications available to help reduce marijuana, cocaine or methamphetamine use. There are now three medications that can be prescribed by a physician that can help you limit your drinking:

  • Acamprosate (Campral) may help you drink less. It will not make you sick if you drink. It might make the effects of alcohol less appealing. The effects of acamprosate last approximately 18 hours.
  • Naltrexone tablets (Revia or Depade) or injectable (Vivitrol) may help you drink less. Like acamprosate this medication helps to prevent relapse and, in patients who lapse, lessen the likelihood of full blown relapse. The effect of daily Naltrexone tablets last about 12-18 hours, a Vivitrol once-monhtly injection lasts 30 days; neither tablet or injectable will make you sick.
  • Disulfiram (Antabuse) will prevent you from drinking. Drinking even a very small amount of alcohol will make you nauseous and possibly lead to vomiting. Warning - this medication should only be taken under physician guidance.

I have a substance use problem but I don't want to go to a treatment "program."

See a private practice psychiatrist, psychologist or counselor

Many people go to private, office-based therapists for a variety of personal problems. Licensed and appropriately trained therapists may help you not only reduce your substance use but also help resolve additional personal, relationship and emotional problems.

If you feel you may need a medication to help deal with any of these problems it is best to choose a psychiatrist, as they are trained physicians who can prescribe medications.

Look for therapists who have experience and specific training in alcohol and drug issues. You can find this information on the Internet and in the telephone directory. Once you do make contact with a prospective therapist, ask directly about his or her training and experience in substance use treatment and about methods of treatment. If the potential therapist has no plan or experience for addressing and monitoring the substance use problem directly, it would be wise to make a different choice.

See a member of the clergy

Many people value spiritual and religious counsel in their daily lives. Though not all clergy have been trained about counseling in matters involving alcohol and drugs, many have. They can be located through the Internet. Again, there should be a plan to directly address the substance use and agreement to pursue a more intensive option if results are not as expected.

Try AA

Alcoholics Anonymous is the most widely available form of intervention and care for alcohol as well as all other types of addiction. It is anonymous, free, there are meetings at virtually all times of the day and there are many locations. It might be wise to go to an AA meeting even if you think this is not for you. You will meet people who will be glad to give you advice and suggestions from their own experience; and hear from them about treatment options. It may not be for you but it could give you some valuable information and it won't cost a thing.

See a specialty physician if you have an opiate problem

If you have a problem with opiates (heroin, methadone, Vicodin, OxyContin, etc.) and do not wish to go to a methadone maintenance program see a doctor who is trained and licensed to provide buprenorphine, which has the brand names Suboxone or Subutex. This is a relatively new medication for the treatment of opiate dependence which is very effective in reducing craving and use. This treatment will also likely involve counseling in addition to the medication, but this too can be provided in a confidential manner. You can find the name of a physician near you who can provide buprenorphine by an Internet search using the name of the medication.

I have a substance use problem that I cannot manage, even with counseling or medication.

If self-management efforts have not worked, it may be time to seek specialty care. Within the category of specialty care programs there are many options. Think about the nature and severity of the problems you are experiencing as you decide which option might be best. Consider the following questions as you make your decisions:

Do you need detoxification or stabilization?

If your use of various substances has really gotten out of control, or you have used significant amounts of various substances for extended periods of time; or you have used significant amounts of alcohol, opiates (heroin, methadone, OxyContin, etc.) you may need a period of medical care to help you stop use safely.

If so, you should call a detoxification center and arrange for an appointment. Sometimes this can be done as an outpatient but most cases require a period of hospitalization for 3-5 days. Following stabilization and evaluation you will have other treatment options described below.

If you do not need detoxification, or you have completed detoxification, do you think you have to get away from your living arrangements to get control of your substance use?

If yes, then you may want to consider a period of rehabilitation care (usually 21-30 days) in a residential program. If you are able to demonstrate the medical necessity of this, private insurance can support at least part of the cost (about $15,000-$25,000).

If you think you could get things under control without going away, then you may be able to do well in an outpatient program. Although you may have to fight hard to gain coverage, insurance companies will usually support at least part of the cost - about $100-$200 per week.

Good rehabilitation treatment programs employ qualified and well trained staff, and offer a range of treatment components (medications, therapies and services) that address the problems of their patients. Better treatment programs have more quantity and better quality of the following components:

  • Therapies and therapists - Does the program have therapists who have been trained and certified in different types of therapy? Do they offer individual therapy as well as group
  • Medications - Does the program have meaningful involvement by physicians and medical staff trained in addiction medicine? Do they offer anti-addiction medications for nicotine, alcohol and opiate dependence? Do they offer medications for treatment of co-occurring mental and physical problems?
  • Family involvement - Family involvement should continue beyond the rehabilitation to help prepare the family for the post-treatment period. Does the program have therapists trained in a specific form of family therapy?
  • Social services - Ask about assistance in getting help with your social problems related to your addiction, such as housing, employment and transportation. These services may help you develop an improved lifestyle that will support your recovery.
  • Urine drug screening - Does the program have randomized drug testing at least once per week? Testing is likely to help improve your motivation and self-management. Finally, your family, employer or other referral source may want evidence of sustained periods of abstinence.
  • Continuing care - Does the program provide telephone or in-person visits following completion of treatment? Are there provisions to link individuals with trained therapists near your home following completion of care?

Do you have an opiate problem (heroin, OxyContin or other pain relievers) and abstinence-oriented treatments have failed?

Consider methadone or buprenorphine maintenance.

A table showing the symptoms of various substance use addictions and the medications sometimes prescribed to treat them.

Prescribed medications to treat addiction, when available, can be especially helpful in the early stages of recovery because they can help people to become stable enough to adopt a workable recovery plan.

Because of changes in the brain caused by long-term use of heroin, OxyContin and other prescription opiates, many people addicted to these substances often need medication. Physicians frequently prescribe one of two medications -- buprenorphine or methadone.

Recent years have brought improvements in the treatment of alcoholism, especially in the medications that can be prescribed to combat alcohol cravings.

Counseling and therapy are essential ingredients of recovery from addiction.