You don't have to go off the grid to get treatment for drug dependence

Every other week stories appear online and in the media about alternative “treatments” for drug dependence. Rock therapy in Kyrgyzstan and vomit therapy in Thailand are two recent examples.

Long waiting lists for drug treatment in Australia and a perception that drug treatments are ineffective may be driving people to seek solutions elsewhere. But these untested interventions are expensive at best and potentially dangerous at worst.

So what treatments do work for ice and other drug users?

Not all drug users need treatment

Different drugs have different dependence thresholds. For most drugs, infrequent, short-term users make up the larger group of people. They eventually stop without experiencing any significant problems.

For methamphetamine (which includes ice and speed), using more than weekly is associated with dependence. Around 15% of people who used methamphetamine in the past year fall into this category.

For cannabis, around 20% of people who have used in the past year are likely to be dependent. Around 4% of drinkers are dependent.

This means that 85% of methamphetamine users, 80% of cannabis users and 96% of drinkers are probably not dependent and are unlikely to need treatment.

Those who are not dependent are still at risk of unwanted side effects and overdose. Harm-minimisation strategies are designed to keep this group, and the community, as safe as possible while they continue to use. Measures include police random breath testing, drug checking (testing the content of drugs) and needle and syringe programs.

Methamphetamine users also commonly experience mental health problems such as transient psychosis (25%) or symptoms of depression (80%).

This group may not be willing, or need, to access drug treatment but may seek help for their mental health symptoms through their GP or other health service. Addressing mental health symptoms can encourage users to seek help for their drug use earlier.

What works for those who need treatment?

The goal of treatment for alcohol or other drug dependence is to reduce use and to improve quality of life. According to the National Institute of Drug Abuse (NIDA) in the United States, people who enter and remain in treatment reduce their use of alcohol or other drugs, are less involved in criminal activity and have better general functioning.

There are also cost savings to the community through better health and reduced crime.

For those people who use alcohol or other drugs and need treatment there are a number of effective options. The Australian Psychological Society has undertaken a review of psychological interventions for mental health conditions and found that cognitive behaviour therapy (CBT) has the best evidence for its effectiveness.

NIDA endorses a number of treatments as effective. Most fit within the group of behavioural and cognitive therapies.

For dependent heroin users and cigarette smokers, and to some extent dependent drinkers, drug therapies are also effective. But for other drugs, medical treatments are generally limited to medicines to relieve symptoms of withdrawal or use such as mental health symptoms.

Drug dependence is a chronic health condition and relapse is likely along the road to recovery. The overall relapse rate is around 50% after one year. This is similar to relapse rates after treatment for other chronic health conditions, such as diabetes, hypertension and asthma. It is also similar to other mental health conditions such as psychosis, which has a reoccurrence rate of 70%, and depression (50%).

The Patient Pathways study in Australia found that one year after treatment, about 40% of dependent users in treatment were abstinent, ranging from 60% (methamphetamine) to 28% (alcohol). However, continuous abstinence was harder to achieve, with only around 30% of people remaining abstinent for an entire year.

But not everyone who goes through drug treatment aims to be abstinent from drugs. Around 55% of people in treatment succeeded in making significant changes to their use.

A follow-up of heroin users who entered treatment found substantial reductions in heroin and other drug use, crime and injecting-related health problems. Reductions were still evident after two years and maintained after 11 years.

When is treatment most effective?

The idea that drug users need to hit “rock bottom” before recovery is possible is not supported by evidence. Many people make significant changes to their use well before they reach crisis point.

Motivation is important in the success of drug treatment, but part of the core skills expected of alcohol and other drug treatment professionals is the ability to increase motivation for engaging in treatment and reducing drug use.

In a study of an intervention for methamphetamine users, which included a motivational component, more than a third of people entering the study were not interested in changing their drug use. But their outcomes were similar to those who were motivated at the beginning of treatment and both groups showed increased abstinence.

Mandated treatment programs, such as court diversion or drug court programs, also show that people who are ordered to treatment through the justice system do well once they get there.

What treatments are available in Australia?

Specialist alcohol and other drug treatment services vary between states.

Publicly funded services are run by government and non-government organisations. These services are generally free or low cost to the consumer. They offer a range of options including outpatient counselling, group programs, rehabilitation day programs (typically six to 12 weeks), inpatient rehabilitation programs of typically between two and 12 months, and inpatient and outpatient detoxification.

The different treatment options show similar outcomes.

In the public sector, most people needing drug treatment choose outpatient counselling, which is the least expensive option.

Although self-help groups are considered peer support rather than treatment services per se, programs such as SMART Recovery and a range of 12-Step programs are widely available. These are usually run by consumers and peers at low or no cost.

Private services are also available in all states, both through hospitals – usually offering inpatient detoxification, inpatient stays of typically up to three months that include individual and group attendance – and private individuals, such as psychologists, psychiatrists and addiction medicine specialists. These services vary in cost, some of which may be claimable through Medicare and/or private insurance.

In Australia, government-funded services are expected to meet minimum standards of accreditation for health providers, and some states require minimum qualifications for practitioners. Private providers, such as hospitals, psychologists, nurses and medical professionals, may be required to meet certain professional standards for registration and accreditation.

However, many providers that offer drug and alcohol treatment, such as “counsellors” and “psychotherapists”, are unregulated. There are also no specific minimum requirements for establishing a private drug rehabilitation program.

Some use frameworks that are not consistent with the evidence. Very few have been independently evaluated. If considering treatment, it is important to check into any potential program to ensure it meets best practice standards.

Evidence-based treatments for drug use problems are available in Australia at low or no cost to consumers, but waiting lists can be long. Public investment in these treatment options for drug users is essential if we’re serious about improving access to and outcomes of treatment.

Innovation is important, but new and untested treatment programs should be subjected to well-conducted evaluation of outcomes to ensure they’re not only doing good but are also doing no harm.

Nicole Lee works as a private consultant to health services and is the President and Board Chair of the Australian Association for Cognitive and Behaviour Therapy