EXPLORING THE TREATMENT LANDSCAPE
This piece takes you through the main types of treatment available for health issues related to drug and alcohol use and the approaches they use. We have outlined the primary forms of treatment available with a quick explanation of each to help you navigate the treatment landscape. Note that you might use several of these in combination.
WITHDRAWAL MANAGEMENT
AKA Detoxification AKA “Detox”
You can detox at home or in a hospital/clinical setting. The best setting for you depends on the substance you have been using, whether you have a safe and comfortable place where you can detox and the level of triggers and stresses where you’re living.
Detoxing off alcohol, GHB and ketamine is dangerous and you can fit. It is best to go to a residential detox unit. You should not jump off drugs like methadone, buprenorphine or benzodiazepines. You need to reduce with a doctor’s support.
Community Residential Detox Unit:
• A safe place to get through the physical symptoms of detox
• Round-the-clock care in a specialised unit
• Usually 4 to 10 days depending on your needs and unit policy
• Abstinence-based but may be medicated
• Can be stand-alone in the community or attached to a hospital, rehab or other multi-function service
• Support workers might do some Cognitive Behavioural Therapy
• May also offer things like “Relapse” Prevention and meditation /relaxation depending on the service and the drug.
• Detox unit are either publicly funded (via your local health district) or within a private hospital/clinic setting (expect to pay up to $2-3,000 per week if you are not insured).
• Detox programs should connect you with post-detox services like Opiate Substitution Treatment (OST), rehab, a day program or counsellor.
Non-Medicated Detox Unit:
• No medical staff but emergency access if necessary
• Staff cannot prescribe or dispense medication
• Most non-medicated detox units allow people to bring in symptom relief for nausea, cramps etc as well as benzos in the case of alcohol, ketamine or comparable detoxes and to access those meds as prescribed - but check first. You are expected to see a GP or other doctor to get your prescription then fill it at a chemist before you arrive at the detox centre. They may require a letter from your GP detailing when and how the meds are to be provided to you.
A Medicated Detox Unit:
• Has full-time medical staff and doctor’s rounds
• Offer benzodiazepines, buprenorphine and/ or medications to relieve the symptoms of detox.
• May be able to start you on longer term bupe or methadone.
Inpatient Hospital Detox:
• Detox in a hospital bed in a regular hospital ward
• Might occur where 1) there is no medicated detox bed available and 2) your detox may be dangerous due to the type of drug/ alcohol you are withdrawing from or your personal medical history.
Ambulatory/Outpatient Withdrawal:
• “Ambulatory” just means “able to walk” and is a fancy name for outpatient
• Available from your local Alcohol and Drug Service
• Staff assist you to plan your home detox
• Offer resources and advice for staying on track
• Given take-home medication to help with withdrawal symptoms like diarrhoea, nausea, cramping and headaches
• phone-in service for extra support.
Home-Based Detox:
• Offered in the cases of complex withdrawals or for vulnerable people such as adolescents.
• All the elements of ambulatory detox plus…
• Daily home visits by a nurse
• Nurse can coordinate medical care and can offer counselling, nutritional advice, relaxation techniques, harm reduction advice.
Primary Care:
• Care offered by a GP in the community
• You can ask your GP to co-ordinate care and prescribe withdrawal medication
• Advantage is that your GP is familiar with your general health needs and can approach your health wholistically
• You need to involve a doctor for withdrawal from alcohol, GHB, or ketamine
• You will need a prescribed reduction regime to reduce from methadone, buprenorphine or benzodiazepines
PSYCHOLOGICAL COUNSELLING
Counsellors AKA Psychologists AKA Therapists
Counsellors are everywhere! In public Alcohol and Drug Services, in rehabs and in private practice. They usually have psychology (as opposed to psychiatry which is a doctors’ specialty) or social work degrees. Check their qualifications and experience. “Psychosocial” means the combination of individual thoughts and behaviours AND social factors and environment (things like education, where you live, how you grew up, cultural barriers, income).
Depending on their training, personal preference or their workplace philosophy counsellors use different types of therapies, sometimes in combination. They also may specialise in areas other than drug and alcohol such as grief and loss or domestic violence. Ask what they specialise in and what therapies they use to guide you. The following therapies are approved in the NSW drug and alcohol counselling arena because they have been proven to get results (they are evidence-based).
Acceptance and Commitment Therapy:
• Long process - often used in rehab situations
• Identify unhelpful filters we put on our world
• Come to terms with our pasts and connect with the “now”
• Helps us recognise that we are all more than what we feel, think or do
• Work out the kind of person we want to be, set goals and learn how to act in new ways.
Cognitive Behaviour Therapy (CBT)
• Research shows CBT is one of the most effective tools we have in changing behaviours
• Helps us unpack the way we think and behave
• Have you ever thought the worst of a situation and ended up getting things way out of whack? CBT can give you the tools to act differently next time.
Dialectical Behaviour Therapy (DBT):
• A type of CBT that focuses on bringing opposite ideas together - in this case action and acceptance.
• All about enhancing capabilities and motivation
• Focuses on difficult situations that arise in our everyday lives.
• 4 key ideas - Mindfulness - living in the here and now; Distress Tolerance - sitting with pain rather than changing it; Interpersonal effectiveness - maintaining self-respect and good relationships with people while asking for what you need and saying no when you need to; and Emotion regulation - how to change emotions you want to change.
Contingency Management:
• Gives actual rewards to reinforce behaviours like abstinence, e.g. a voucher for a clean urine
• Based on conditioning theory which argues that rewarding particular behaviour means that you will do it more frequently
Community Reinforcement Approach (CRT):
• Based on the idea that the environment plays a powerful role in encouraging or discouraging drug use
• Aims to make living without drugs more rewarding than living with drugs by finding healthier ways to be happy and avoid unhappiness
• Teaches life skills to increase participation in the community
• Involves significant others in treatment Couples and Family Therapy (CFT)
• Positive family relationships are important for good mental health
• Works with families and couples to bring about change and development.
• Teaches better ways of being with our children, parents, partners
• Teaches our behaviour is not just about us - it affects all those who love us Motivational
Enhancement Therapy (EMT):
• Comes from Motivational Interviewing (MI)
• Designed to help people who are sitting on the fence
• Quick, over just a few sessions, to get people thinking about their drug use and building a plan for change
• Focus on imagining your life without drugs
• May ask people: What do you want out of life? Where is your life now? How do you jump the gap? Might changing your drug use help you reach your goals quicker?
• Helps people developing commitment to their end goals.
You will also hear these following terms used. Some are used as part of other techniques.
Mindfulness Training:
• Manage stress by learning to pay attention to the moment you are in through meditation then carry that into your life
• All about getting skills in living in the “here and now”
Strengths Based Approach:
• Empowers you by helping you identify strengths and assets
• List could include personal qualities like open-mindedness and empathy; partnerships with family, partner and communities; and supports like housing, work, education
• How to use your assets to get the results you want.
Case Management Approach:
• Each service user is under a specific drug and alcohol worker who helps them work out personal goals, links them with other services, writes letters of support for court, housing services and children’s services, monitors treatment and generally goes in to bat for them when they need a bit of support.
Narrative Therapy:
• Movement away from blame and guilt and the idea that we are “bad people” because we have had difficult lives
• The motto? “The person is not the problem, the problem is the problem.”
• This separation (called “externalisation”) allows us to step out of our lives to look at how our problems affect us then work out an alternative way of being
• It’s about finding new ways of being in the world
There are a number of other therapy types that are commonly employed but do not have a strong evidence base including gestalt, transactional, hypnotherapy and psychoanalysis.
RESIDENTIAL TREATMENT
AKA Rehabilitation Facility AKA “Rehab”:
Rehab offers a live-in, extended and concentrated based program of change. Most rehabs are abstinence based. The main benefit is a safe drug-free environment where people can have some time away from triggers like day-to-day stresses and friends who are still using. Because people spend long stretches of time in rehab, there is space to look at issues behind their use and begin behavioural changes.
• A structured program using case management and group work
• There is a focus on wholistic care. Different rehabs will have different programs ranging from health care, living and social skills, parenting skills, physical fitness and accredited workplace skills training.
• Live-in for several weeks to several months
• Often in the country or semi-isolated area
• Regulated environment to build skills and self confidence
• Full-time staff on premises
• Some rehabs allow children and some focus on women who are under FACS direction
• Some rehabs have places for participants in various court diversion programs
• Some incorporate a stay in a community half way house in the city in the final stages
OST Reduction:
• Residential program
• Goal of abstinence
• Allows reduction from OST safely
A Therapeutic Community (TC):
• A style of residential treatment where the community is not just where you live, it’s how you make change.
• A group of people who share common treatment goals come together to work on changing behaviours.
• Therapeutic staff are part of this community, overseeing and directing the group, but the functioning of the group and therapeutic discussion are generally peer led.
• TCs can also work in Day Programs where members of the community are together each day but go home at night.
Supported Accommodation:
• Offer long-term residential accommodation in home-like environments
• People live semi-independently with support.
• Residents may suffer from a mental illness or need other ongoing support
• Support workers are available to help residents plan and refer to other services as required.
Opiate Substitution Treatment (OST) Stabilisation:
• Residential program
• Provides a safe and regulated environment for people on opiate substitution to become abstinent from other drugs or use their OST as prescribed
• No pressure to reduce from OST
• OST regarded as legitimate treatment
SUBSTITUTION TREATMENT
AKA Replacement Therapy AKA Pharmacotherapy AKA “On a Program”
Substitution Treatment involves replacing illegal drugs or drugs taken illegally with a replacement drug taken orally. The replacement is offered under very strict guidelines monitored by the NSW Ministry of Health.
OPIATE SUBSTITUTION TREATMENT (OST)
AKA “On methadone/’done/buprenorphine/bupe/Suboxone”
In NSW, we have methadone / Biodone (alcohol/sugar free version of methadone) and buprenorphine in the form of Suboxone strips (buprenorphine + naloxone). These are offered through a number of services. Also see our articles on OST.
Community Chemist:
• Will usually dose whenever they are open
• Can charge what they want but usually prices level with other chemists; may be able to negotiate if you’re unable to pay
• May only offer Biodone or methadone, not both
• Follow prescription of doctor
Community Prescriber:
• Doctor (may be GP or specialist) who has completed OST courses required by NSW Ministry of Health
• If a specialist in drug and alcohol, most will have FRACP FChAM after their name
• Have their own policies outside an institution so can negotiate with them re urine/blood testing, doses, takeaways and costs. May be willing to prescribe Suboxone so you can pick up a month’s worth at a time from a chemist
• Some will co-ordinate other health care, others will only deal with your OST
• Can provide prescription to a private clinic or chemist for dosing
• May not bulk bill or may charge gap fee, but may be willing to negotiate
• NSW OST Guidelines open to interpretation by your prescriber but they must document their decisions
• Can determine how frequently you see them - your script may last a week or several months.
Public Clinics:
• One-stop shop with a team of doctors /prescribers, nurses / dosing staff, psychologists / counsellors, social workers, admin etc
• Offer Biodone and Suboxone (daily or every 2 days)
• Case management approach and access to a social worker
• Need to attend every day. Takeaways are rare - need a good reason and paperwork
• Free
• Require random urines
• Will co-ordinate relevant health care e.g. testing/treatment/immunisation/dosing around blood borne viruses (hep C, hep B, HIV) and mental health issues.
Private Clinics:
• Provide doctors /prescribers, nurses / dosing staff, administration.
• May offer Biodone and/or methadone. Offer Suboxone strips
• Offers takeaways
• Require random urines
• Highest charges of all options; start up fee; extra fees on takeaways.
Primary Care:
• GPs who have not completed training can prescribe OST for up to 5 people
• Can take over prescribing for stable patients but cannot start treatment
STIMULANT SUBSTITUTION TREATMENT (SST)
In NSW, there are only a few places that offer SST. Dexamphetamine (dex) is offered by clinics and less than 2 dozen people in NSW are on it at any one time. Modafinal can be prescribed by a doctor under certain conditions, however there is not adequate research on whether it’s effective.
Stimulant Treatment Programs:
• Offer a stepped approach to stimulant treatment with an emphasis on counselling
• Dosing with dexamphetamine (dex) is available for a very small percentage of people under very strict guidelines.
• Requires two psychiatrists/specialists to prescribe dex
Primary Care:
• Your GP may be willing to prescribe Modafinal for oral use
YOU DECIDE. REALLY.
Most people that have been to a few “Alcohol and Other Drug” treatment services have a negative story about at least one of them. Choosing the type of help, support or treatment that will fit for you can be a case of suck-it-and-see. Before you contact a service, there are a few things that might be helpful to consider and hopefully make the experience a little easier.
Think About What Help You Want
Do you want treatment, a health check-up, support, medical assistance or advice? Something else?
Do you want a free service or can you afford to pay?
What are your obligations and how much time do you have?
Consider Why You Want it
What is going on in your life around substance use that has you considering treatments?
Do you want to deal with an issue or issues that are not about drugs or alcohol but related like family, trauma or financial matters?
Be Clear About What Outcome You Want
What are the changes you want to make in your life?
Do you want to stop using drugs and alcohol altogether?
Do you just want to stop using a certain drug?
Do you want some time out to get healthy?
Get Your Team Together
Once you are fairly clear on what you want and why you want it, enlist some help. Making change is a hell of a lot easier to do with a team behind you. Talk to peers, friends, family, your NSP worker, welfare workers, your GP, a counsellor on a phone service, NUAA staff... whoever is on your side! Research shows that when we have support from family and friends it’s amazing what we can achieve. When we ask for help to make life change, it’s amazing how many people step up.
Ask Questions
You can read a whole lot about different programs available, and mostly the information is presented in a way to make the service look attractive. The map is not the territory! Contacting a service with a list of questions is a fantastic way to get some idea of how they treat people. How they respond when you start asking them questions about their program, approach, qualifications of staff, restrictions and rules will certainly give you some idea of how you will be treated!
Why Are We Waiting?
You may feel like if you don’t start NOW that the opportunity will be lost. But waiting is often part and parcel of getting help. To start with, there are not enough services so you may have to go onto a waiting list. As well, most services require phone assessments and other information before you even get in the door. Going on methadone or buprenorphine requires waiting for Ministry of Health approval.
Just stay focused and in their face. It will speed things up if you find out what the service needs from you and doing it. This may mean getting your ID and other paperwork ready and ringing them every day.
Home or Away
The most common consideration for people is “Do I want to go and stay somewhere or do I want to stay at home?” This often hinges on whether you need to meet responsibilities around things like caring for children or elders, working and maintaining your housing.
It also depends where you are in your life, what you want from the service and what you feel your best chance for success is. Talk to people, search the net, and look past the glossy brochures!
Choices, Options and Alternatives
There is a variety of Drug and Alcohol treatment options available - have a look at our list in this issue. Sometimes your first choice isn’t available right now. Think about trying something else in the meantime, it might just be the thing that helps. Mixing it up can work too - try a combination of things.
Remember just because something didn’t work for you at one time in your life doesn’t mean it won’t work now. Just because it didn’t work for your friend (or someone telling their story in this mag) doesn’t mean it mightn’t work for you. And if something isn’t feeling right, change tack and try something else.
If at first you don’t succeed, try again! Go for things that are proven to work by a reputable research team. If you don’t trust your own judgment, ask someone you admire for their opinion. But at the end of the day, it is your life and your choice.
Tell Me More
Read up on treatment options in this edition of User’s News. If you would like to learn more, you could call NUAA on 02 8354 7300 or 1800 644 413 and talk it through with our very knowledgeable and experienced staff. Or contact phone service ADIS (Alcohol and Drug Information Service) for some guidance. Not only do they have hundreds of services in their data base, they are skilled counsellors who can ask you some questions to help you make up your mind.
Numbers:
NSW - 02 9361 8000 /1800 422 599
ACT - 02 62054545
QLD - 07 3236 2414
NT - 08 8922 8399
WA 08 9442 5000
SA 08 8363 8618
TAS - 03 6233 6722 VIC - 1800 888 236