Recovery from chemical dependency occurs in three phases: Transition, Stabilization, and Rehabilitation. "Primary Domain Outcomes" pertain to the first two phases; "Secondary Domain Outcomes" pertain to the third phase. The proper focus of chemical dependency and substance abuse treatment programs is upon the Primary Domains of transition and stabilization. Acute Detoxification is a necessary entry point and precursor for alcohol and drug treatment. Primary strategies are drug therapy, environmental cloistering, and acupuncture. The Stabilization phase is aggravated by post-acute withdrawal. Competent and successful programs need a structural foundation that will retain clients through periods of acute and post-acute withdrawal and which can retain clients in treatment in spite of relapse. Acupuncture has the capacity to provide a foundation for outpatient treatment necessary to attract the attention of clients, engage them, and retain them long enough for stabilization to occur.
Treatment and the achievement of successful recovery from chemical dependency can be viewed as occurring in three phases: (1) Transition from substance use to non-use, also called the Assessment Phase, lasting from thirty to sixty days; (2) Stabilization, lasting from thirty days to twelve months, in which non-use becomes established as a way of life, and (3) Rehabilitation, lasting from twelve months to three years or longer, during which vocational, educational, housing, and relational outcomes are achieved.
For purposes of this discussion, treatment outcomes are divided into two domains: "Primary Domain Outcomes," which we define as those outcomes and success indicators that pertain to the first two phases of Transition and Stabilization, and "Secondary Domain Outcomes," which pertain to the Rehabilitation phase.
In conventional treatment programs, the focus of outcomes (as well as a substantial dedication of resources) is often in the Secondary Domain. These outcomes concern such things as improvements in employment and housing, and reduction in criminal activity and emergency medical services. This focus is understandable from the funders or investors perspective, since these are the outcome domains which addresses the negative costs to society of untreated chemical dependency (see The Cost of Untreated Chemical Dependency).
Client retention is the central, necessary, and overarching goal of all substance abuse and chemical dependency treatment. Stated simply, if the treatment program can retain clients in treatment long enough for something significant to happen for them, then the client has a chance of achieving and maintaining rehabilitation; if the program cannot, the clients chances of achieving and maintaining sobriety are slight.
Rehabilitation, inotherwords - or "Secondary Domain Outcomes" - will never be achieved if successful Transition and Stabilization do not occur. Conversely, if clients can be retained in treatment during the Transition and Stabilization phases, a significant percentage of them will naturally seek improved housing and employment, and will have reduced criminal justice and emergency health care utilization, either on their own or with minimal case management support and assistance from the program.
The proper focus, therefore, of chemical dependency and substance abuse treatment programs is upon those outcomes and success indicators in the Primary Domains of transition and stabilization.
The purpose of this paper is to suggest outcomes and milestone indicators that are appropriate for these primary phases, and to explore strategies that contribute to their achievement.
Acute Detoxification can be viewed as a relatively brief (7 to 21 days) clinical subset of the Transition phase. Meaningful assessment and diagnosis is generally not achievable during the detox phase as the presence of acute withdrawal symptoms exacerbates clinical or psychiatric diagnoses, and patients are often incapable of delivering reliable and detailed historical information. Therefore, after addressing emergency medical or social issues, detox treatment plans are generic in nature, focusing on cessation of substance use, and on activities to physically support the patient in the acute withdrawal process.
Acute Detoxification as a chemical dependency treatment component is not usually regarded as having much intrinsic clinical integrity. "Detox" is viewed rather as a cumbersome but necessary "purgatory" to which people retreat until they are ready to begin the serious work of treatment and recovery. Identifying predictors of long term success among acute detox clients is nearly impossible: people who demonstrate high motivation at intake may fail, and those who appear highly resistant may succeed. Further, successful detox completion in itself has not been found to correlate with successful longer term recovery outcomes, and detox programs are therefore often characterized as "revolving doors" since most chemically dependent consumers will attempt and succeed at detoxification numerous times before ultimately achieving recovery. For this reason, "free standing" detoxification without follow-up support is generally viewed as non-productive.
And yet, detoxification is a necessary entry point and precursor for alcohol and drug treatment, because the cessation of alcohol or illicit drug use is ipso facto the foundation for any further therapeutic movement.
A first base-line success indicator for this initial stage is that "__% of clients will abstain from alcohol and illicit drugs." This can be verified by urine or breathalyzer test or by observation of staff.
The focus of acute detox is to address alcohol or other drug withdrawal - sometimes called "abstinence syndrome." Detoxification can be defined in physical terms as a crisis of elimination (Smith and Kahn, 1988). Therefore, most detox focus is upon management of acute withdrawal symptoms. These symptoms, which vary depending upon the clients drug of choice, include craving, anxiety, depression, tremors, excessive sweating, loss of appetite, sleep disturbance, nausea, headaches, and gastrointestinal problems.
A second recommended primary base-line outcome success indicator may therefore be stated: "___% of clients will experience a reduction of the presenting symptoms of acute withdrawal." This may be verified by self-reporting or by medically diagnostic monitoring.
Two strategies have historically been taken to manage withdrawal symptoms, and may or may not be combined. The first is drug therapy, either in the form of "replacement therapy," which is the administration of drugs with similar actions to those of the drug from which the patient is withdrawing - diazapine, Librium, or Phenobarbital for alcohol and other sedative hypnotics, and Haldol, methadone, or buprinephrine for opiates - or blockers such as Antabuse for alcohol, or naltrexone for alcohol or opiates.
The second strategy is environmental, cloistering the patient in a drug-free setting, which may or may not be accompanied by emotional support or physical activities. Indeed, alcoholics and addicts will often self-impose this latter modality on their own without the assistance of a formal treatment setting.
Acupuncture provides a third strategy (see Acupuncture: New Perspectives in Chemical Dependency Treatment). This is a useful component in that (1) it can be easily blended with either or both of the first two strategies; (2) it has been shown to significantly reduce all withdrawal symptoms, including craving, and (3) it is cost-effective, safe, flexible, and portable.
Acupuncture also provides a drugfree orientation to sobriety maintenance, and makes possible a highly cost-effective new option: outpatient drugfree detoxification. Twice-daily acupuncture provides a level of physical and emotional support that allows clients to achieve detoxification on an outpatient basis. Clients may be housed in homeless shelters or other settings during the detox phase. Alcohol, minor tranquilizer, or barbiturate seizures virtually disappear with daily acupuncture (Lane, 1988).
The most significant and potentially problematic fact in chemical dependency treatment is that withdrawal persists beyond the acute detoxification stage. Post-acute withdrawal - sometimes called "protracted abstinence syndrome" - is characteristic of all major psychoactive drugs of abuse. It is a cycle of craving, anxiety, depression, and often sleep disturbance that continues for months (and sometimes even years) following cessation of drug use. This is an emotional or psychological syndrome, but it is also a physical one caused by the neuroadaptation that results from chronic psychoactive drug use - alterations in dopamine, serotonin, norepeniphrine, and other neurochemical production and regulation
Program components such as counseling, education, relapse prevention, case management, or psychotherapy, are not to be disparaged. Each can have a profound impact on client retention. However, no matter how rich the program is in these components, if the program lacks effective strategies for managing the physical symptoms of acute and post acute withdrawal, it is unlikely that clients will be emotionally available to avail themselves of these more cognitive elements. Any cognitive intervention is likely to be unproductive if the client is in a state of intense craving, anxiety, or depression.
Competent and successful programs need a structural foundation that will retain clients through periods of acute and post-acute withdrawal.
Our third success indicator, therefore is that "___% of clients will remain in treatment and continue to comply with their treatment plan for a period of (30) (60) (90) days in spite of relapse.
We say "in spite of relapse" because relapse is so common in the Transition and Stabilization phases that many consider it inevitable. To be effective in terms of retention, it is therefore essential that the program be "user friendly" or relapse-tolerant - that it be able to retain clients in treatment in spite of relapse.
We therefore suggest a practical distinction between a "use episode" and a "relapse." A "use episode" is non-catastrophic in that it does not result in treatment drop-out. A "relapse" results in treatment cessation and discharge. In this sense, the goal of the program is to convert "relapses" to "use episodes."
One way of framing the problem of client retention during the Primary treatment phases is to ask the question, "What can we do in the design or our services to make them competitive with the things we are asking our clients to give up? What can we offer in the structure of what we do that can compete with, or replicate in a positive way, or mirror the things that our clients are doing outside at a level that will attract their attention, engage them, and retain them long enough for something significant to happen?"
Psychoactive drugs used in treatment can help to achieve the goal of attracting the attention of clients, of engaging them, and of retaining them. Indeed, the literature of drug treatment is largely a discussion of drug replacement therapies, and these therapies, such as methadone, do in fact have the ability to compete with, replicate, or mirror some of the things that clients are expected to give up. Methadone programs have reasonable retention rates.
But if we seek a structural foundation that is beyond simple maintenance, which is oriented toward the cessation of all psychoactive drug use, and whose goal is the initiation of recovery and rehabilitation, we are challenged to explore new modalities and methods that will provide a organizational foundation for client retention.
Foundations are, by their nature, often beneath conscious awareness and attention. The foundation of 12-Step programs, for example, is anonymity. People can attend 12-Step meetings, work the steps, sponsor people, and yet not be conscious of the fact that anonymity is the foundation. A few simple protocols practiced in 12-Step programs assure this foundation. Similarly, if a house has a good and strong foundation, people can live in the house and do things in the various rooms and not be consciously aware of the foundation. One who is enjoying the benefits of a good foundation, inotherwords, need not necessarily be aware of the foundation. It functions just the same. It is "automatic," or "built in."
Acupuncture has the capacity to provide such a foundation for the outpatient treatment program. There are three ways in which the acupuncture modality provides the deep structure necessary to attract the attention of clients, engage them, and retain them long enough for something significant to happen.
1. Acupuncture provides consistency.
The first foundation element of the acupuncture modality is its unique ability to provide consistency. Chronic alcoholics and drug addicts crave consistency. This may seem a paradox in that their lives are generally characterized by inconsistency and unpredictability, but this is the very reason that they crave consistent experience. They seek and find this consistency in their drugs. Often, their drugs and the mental and emotional states they elicit are the only consistent thing in their lives. In the beginning, they were perhaps motivated by novelty-seeking, but in the later or chronic stages they are far more interested in consistency, which is evidenced by how particular and meticulous alcoholics and addicts generally are about the brand, supply, dose, and strength of their drug(s), their synergistic effects, and so forth. A primary reason for this is that the motivation to take drugs in the chronic stage is in the amelioration of the symptoms of acute withdrawal. Alcoholics and drug addicts are going through detoxification every day, whether they are in treatment or not; they are engaged in the daily, methodical, and formidable task of masking and suppressing the discomfort of these symptoms with more drugs. This requires a fairly high degree of precision, attention, and consistency in dose-response.
The 5-point auricular (ear) acupuncture modality endorsed by the National Acupuncture Detoxification Association has the ability to provide this consistency of experience and hence to replicate or mirror in a healthy way an important element of what we are asking them to give up. Talk therapies, as rich and diverse as they may be, cannot provide this level of consistency since they are dependent to one degree or another upon the personality, skill, style, and even the mood of the person delivering the service.
The treatment effects of ear acupuncture, on the other hand, are predictable and consistent independent of the acupuncturist who is delivering the treatment. The treatment is generic, and does not vary significantly based upon presenting symptoms or diagnosis. While the technique and strategy of choosing ear point location may vary slightly among different acupuncturists, the treatment experience is largely comparable to the last treatment, to the one before that, and so on. This consistency is supported by offering the treatment at the same time every day.
This element provides a vertical flexibility parallel to a 12-Step meeting, from which a participant can gain a predictable benefit regardless of the stage or phase of recovery that they happen to be in.
2. Acupuncture works in the present moment.
Most alcoholics and drug addicts are oriented toward living in the present moment. It is usually difficult for them to realistically project the consequences of actions into the future, or to relate present circumstances as being a consequence of past actions. The past in general is too painful to entertain, and while many alcoholics or addicts may have frequent reverie or fantasy about the future, they are usually not oriented toward realistic planning for the future. This is one reason why the 12-Step cliché of "one day at a time" is fairly easy for alcoholics and addicts to identify with.
Psychoactive drugs operate in the present moment. It is for relief in the present moment that alcoholics and addicts ingest drugs.
While psychotherapy seeks to operate in the present moment through accessing current feelings, much talk therapy in the stabilization phase of recovery is limited to the past and the future. Examples are, "How old were you when you first started using drugs?" or "How did it make you feel when that happened?" or "Can you think of some things you might do differently if that situation happens again?" etc.
For people to be able to function in relation to past and future, they need to have the capacity to be in the present. If they have no comfortable "place to stand" in their present experience, they are not likely to be able to work constructively with past or future issues.
Acupuncture operates in the present moment. It does not operate on a linear or horizontal plane, but on a vertical one, directing the attention inward toward the sources of healing. The goal of this therapy is not that people get well, which is unrealistic, but that they get better. Inotherwords, while it is not likely that the acupuncture will alleviate all of the symptoms of acute or post acute withdrawal that the person is experiencing, it may give them enough hope and strength to make that discomfort endurable. If successful, they will reduce use and return tomorrow. Because, if we can offer them something that makes them feel better in the present moment without drugs, we will have given them something that they may not have experienced in many months or even years, and this is something to which they are likely to return.
3. Acupuncture is a ritual experience.
Addictive drug use is an experience surrounded by ritual. Each drug has its own culture and its own rituals that govern the procurement, preparation, and ingestion of the substance and the paraphernalia that is used. If one speaks with a newly recovered alcoholic or addict, one might even conclude that the person is as "hooked" on the rituals attending the use of the drug as they are on the effects of the chemical itself. Much relapse prevention work is indeed directed toward the rituals surrounding drug use that become, in recovery, relapse triggers - the "people, places, and things" associated with the use of the drug.
One function of rituals is that they give meaning to life, and we live in a culture that is lacking in ritual experience. Indeed, one of the reasons that people, especially young people, may be so attracted to addictive or drug cultures is the element of ritual that attends these cultures.
When an individual is faced with the prospect of giving up addictive drug use, they are also faced with giving up the attending rituals with which they may have formed a primary identification. Effective treatment must be structured to help provide ritual alternatives to compensate for this loss.
12-Step programs achieve this compensation for many people. Attending a 12-Step meeting is a ritual experience. The meeting always begins and ends, without deviation, with the same words spoken and the same formalities. The words spoken at the opening of the meeting are an invocation for what is to follow. The invocation creates, within the meeting, ritual space in which healing can occur. Indeed, another principle function of ritual is to invoke an opportunity or "space" for healing, for transformation, or for spiritual experience.
Coming for acupuncture is a ritual experience. A mild and pleasant "detox tea" is served, and that becomes part of the ritual experience. More important is the design of having the client do for themselves everything that they possibly can, such as signing in in a clinic log, getting their own treatment card for the self-monitoring of withdrawal symptoms, selecting their own disposable needles, opening the packet, prepping their ears with an alcohol pad, and taking their own needles out at a mirror following the 45-minute treatment. All of these things are quickly learned, adopted, and seriously undertaken by the acupuncture program client as a part of a recognized ritual. And, as is the case with the 12-Step meeting, these repetitious behaviors invoke the "content" of the treatment experience which, again, gently directs the attention away from external or linear matters and inward toward the sources of healing and transformation.
In these three ways, the deep structure of the acupuncture treatment modality has elements that help attract the attention of clients, engage them, and retain them in treatment. It therefore provides a foundation of recovery that greatly enhances and enriches the other diverse modes of service that the program offers. It provides clients with something recognizable, personal, meaningful, and consistent to which they can return at any time regardless of how they are doing in other areas of their lives or in other parts of the program.
Michael Smith and I Kahn, "An Acupuncture Programme for the Treatment of Drug Addicted Persons,: Bulletin on Narcotics XL (1988), 35-41.
Carolyn Lane, "Final Evaluation Report: Acupuncture Detoxification Project," Hooper Center, Central City Concern, Multnomah County, Oregon, Alcohol and Drug Program (1988).
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