Heroin Treatment: Behavioral Approaches

Heroin abuse is a type of learned behavior that must be stopped and replaced by healthier behaviors. Psychological treatment helps heroin abusers to understand their feelings and behaviors and to make changes in their lives that will lead to ending drug use. A behavioral approach to the treatment of heroin abuse can be especially effective when combined with medications such as methadone.

In addition to their drug problem, drug abusers may have psychiatric problems, such as depression or anxiety disorder , as well as problems interacting with other people or dealing with anger and frustration. Psychological treatment can help heroin abusers cope with these problems. Many people who try to stop using heroin end up relapsing, or returning to drug use. Relapse to drug use following treatment can occur because the drug abuser spends time with drug- using friends, feels depressed or angry, and/or lacks the social skills necessary to function in daily life. Patients can learn how to cope with all of these problems by working with psychologists and other counselors trained in behavioral approaches.

The Development of Heroin Abuse

People who try injecting heroin may be acting out of curiosity, hoping to use the drug without becoming addicted. An immediate "rush" follows the injection, with feelings of relaxation and well-being. As users take more of the drug, they become physically dependent on it and experience withdrawal symptoms (such as cramps and irritability) if they stop taking the drug. At this point, individuals may start using the drug both for its positive effects and to get relief from uncomfortable withdrawal symptoms. Whatever the reasons for the person's first use, continued use soon becomes a priority. Some addicted individuals may commit crimes to get money to buy the drug.

Heroin abusers usually have mixed feelings about seeking treatment, because they like taking drugs and do not see why they should stop. They are most likely to begin treatment following a crisis caused by their drug use, such as a problem with the law, their health, their family, or their job. Friends, family, or the legal system may refer them to treatment, which may also be required as a part of a criminal sentence of probation.

Heroin abusers are often also addicted to alcohol and/or other drugs, including cocaine and benzodiazepines (such as Valium or Xanax) that they may have started taking before or after they began using heroin. As a result, heroin abusers have an addictive lifestyle. Treatment of heroin abuse must address these other addictions as well.

The treatment approaches discussed here differ from each other in terms of the specific approaches they take and goals they set. However, all aim to eliminate the drug use of the heroin abuser and to substitute healthier behaviors.

Treatment Settings for Heroin Addiction

Treatment for heroin addiction is offered in publicly funded clinics that accept patients with limited resources, including those who receive public assistance. It is also treated in private programs that take patients with higher incomes and/or medical insurance. Clinics may offer treatment on an outpatient or inpatient basis. In methadone maintenance treatment, an outpatient may receive counseling and psychological treatment, but these are second in importance to daily appointments to receive doses of medication. At the opposite end of the spectrum are residential (live-in) treatment communities and self- help programs that use the Twelve-Step approach developed by Alcoholics Anonymous. In these programs, the treatment addresses heroin abuse as a behavior in need of change and does not make use of medications.

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Therapeutic Communities

Therapeutic communities are long term (from 6- to 24-month) residential programs developed specifically for helping drug abusers change their values and behaviors in order to live drug-free. These communities recognize that heroin abusers have usually been involved in a drug subculture, or separate and secretive drug world, for most of their lives. These drug users need to learn how individuals who do not use drugs function in society. The goal is to rehabilitate the drug abuser into a person who can live in keeping with society's values and goals, hold a job and maintain relationships, and make contributions to the community.

During treatment, the drug abuser lives in a special residential community with other drug abusers and with therapists who may be ex-addicts in recovery. A system is set up to reward the participants for desirable behaviors. These rewards might be community privileges and increased responsibilities. In addition, patients learn through observing peers and staff, who serve as role models for appropriate behavior, sometimes called "right living."

Patients progress through three stages. In the first stage, the patient learns about the therapeutic community by attending seminars. The second stage is called primary treatment, during which the patient takes on work responsibilities and attends group meetings, eventually becoming a group leader. The final stage, reentry, focuses on preparing the patient to separate from the treatment center and rejoin the outside community. It is expected that, after they leave, patients will set up their own households and get a job or continue their education. These programs attempt to rehabilitate drug abusers by helping them adopt a whole new set of attitudes and behaviors. Treatment programs modeled after therapeutic communities are becoming increasingly popular for use in prison systems.

Drug-Abuse Counseling

This approach is practiced in methadone maintenance programs, where patients are required to see a counselor throughout the course of treatment. It may also be provided in outpatient community–clinic programs. Counselors are usually professionals with a college degree in counseling, although ex-addicts who have personal experience with recovery from drug abuse may also provide counseling.

Counselors make sure that the patient is attending regularly and providing urine specimens for drug testing as requested. They confront any violations of program rules, and enforce penalties and privileges. Counselors also design a treatment plan that sets goals for the patient. For example, a treatment plan may contain recommendations to avoid all drug use, get a job, and participate in self-help groups. Patients learn to set reasonable goals (finding a job, starting a bank account, obtaining a driver's license) that will lead to a responsible, drug-free life.

Patients also learn how to solve everyday problems and to make good decisions. Counselors encourage patients to try new social and recreational activities that can replace their typical lifestyle of searching for drugs or hanging out with drug-using friends. Finally, counselors are expected to refer patients to other community-helping agencies for services that they cannot provide themselves. For example, patients who are unemployed may be referred to an employment- counseling service.

Motivational Incentive Therapy

Heroin abusers typically find the temptation of drugs impossible to resist. The goal of motivational incentive therapy is to help patients not only resist drugs but to see that abstinence is a more desirable way of life. The treatment gives patients an incentive—a motive or reason—to remain abstinent. In the program, drug abusers can earn points that are worth money or gift certificates each time they submit a urine sample that tests negative for heroin and other drugs. In general, the more money that is offered, the more successful the incentive program. For example, in some of the most successful programs, patients have been able to earn up to $1,000 if they remained abstinent for three months.

Patients like the incentive program because they can use the money earned to improve their life. For example, they can pay bills or exchange gift certificates for groceries and other items. The incentive program usually lasts for only three to six months. However, the program helps keep patients in treatment and promotes abstinence. During periods of abstinence, counselors and patients can work on making the lifestyle changes that will be necessary after the program ends.

Psychotherapy

This type of treatment, usually practiced by psychologists, psychiatrists, or psychiatric social workers during one-on-one sessions with the patient, helps patients gain insight into their lives and behaviors. The therapist listens sympathetically and patiently, and tries to understand the patient's problems without judging or criticizing. Psychotherapy can also be practiced in groups. Group treatment is popular and may be found in most treatment settings, including hospitals, outpatient programs, methadone programs, and therapeutic communities. Groups provide mutual encouragement and support among people who share similar problems. Patients in groups may benefit from the experience of others in solving these problems.

Relapse Prevention

Some therapists practice an approach called cognitive-behavioral therapy. They try to change patients' behavior and thinking without expecting to find insights into why patients began the behavior. Their main goal is to prevent relapse to drug use, rather than to identify the reasons why patients first tried drugs. Relapse is a serious problem in heroin abuse, so therapists try to teach patients the skills necessary to become and to remain drug-free.

Together, the therapist and the patient decide which factors (such as thoughts, places, people) are most likely to contribute to ongoing drug use or to act as triggers for relapse. Specific treatments then address these triggering situations. For instance, patients learn how to avoid drug-using friends and to stay away from places where the patient has bought and used drugs in the past. In some cases, patients may even want to change their phone numbers or move to new locations. Heroin abusers learn relaxation techniques to deal with stress, so that stress is less likely to trigger a desire for drugs. In addition, relapse-prevention therapists consider the way patients think before an episode of heroin use. These thoughts might be: "I must be loved and accepted by everybody or else I am a failure and might as well use drugs," or "I will never be able to stop using drugs because I am an addict." The therapist aims to change these negative ways of thinking. The patient learns new ways to think positively, such as: "I do not need everybody's approval," or "I can learn to gain control over my behavior."

Effectiveness

Several types of treatment for heroin abuse can be effective, but the best chances of success occur when patients remain in treatment for long periods. Studies have shown that the most effective treatment is a methadone-maintenance program combined with a variety of behavioral approaches, including counseling, individual psychotherapy, relapse prevention, and motivational incentive therapy. Drug use and crime can be reduced, and patients can improve the way they function as individuals and as part of society.

see also Heroin; Heroin Treatment: Medications; Methadone Maintenance Programs; Opiate and Opioid Drug Abuse; Tolerance and Physical Dependence; Treatment: History of, in the United States; Treatment Types: An Overview.