Rehabilitation/Treatment Programs

Since the first decade of the 20th century, public policy in the United States focusing on aberrant use of illegal psychoactive substances has moved back and forth from emphases on punitive and therapeutic interventions. Systems based on therapy and treatment grew enormously during the 20th century, but there were simultaneous increases in numbers of drug offenders being imprisoned and in average length of sentences. Thus, as social policies, the punitive and therapeutic responses exist side by side, with dimensions of both conflict and cooperation. Among the most recent developments are referral of some first-time offenders into treatment as an alternative to prison, and the introduction of treatment delivery within prisons.

Substance use rehabilitation and treatment refers to the management of physical and psychological dependence on, or misuse of legal and illegal psychoactive substances. The most common such substances are alcohol, nicotine, prescription medications, cocaine, club drugs, crack cocaine, depressants/sedatives/hypnotics, marijuana, inhalants, heroin, LSD, methamphetamines, and opioids. Substance use rehabilitation and treatment is needed among such diverse subpopulations as adolescents, older adults, women, combat veterans, professionals, offenders, individuals with HIV/AIDS, people with co-occurring disorders, and the homeless.

In 2007, 23.2 million Americans were in need of treatment for substance use disorders (SUDs). However, only 3.9 million Americans ages 12 years and over received treatment. A survey identifying individuals whose reported symptoms indicated treatment need but who did not receive treatment revealed that 94.4 percent did not think that they needed treatment and 4.1 percent did not seek out treatment despite their awareness that they needed help. Only 1.4 percent of individuals were aware that they needed treatment and made an effort to elicit help. These remarkable data clearly raise issues about the attractiveness of proffered treatment and about the gap between the definitions of drug-related impairment held by researchers and parallel definitions at the community level.

Goals of SUD treatment have varied across cultures, over history, and across psychoactive substances. Patients may be encouraged toward complete abstinence from either all substances or some substances (e.g., abstinence from alcohol but not tobacco products), reduction in the use of substances (e.g., decrease the number of drinks per day, reduce the number of drug use episodes per week, cessation of one drug but not another/others), return to employment, to re-integration of individuals with SUDs into society (e.g., drug offenders). Abstinence goals are dominant across the treatment system. Increasingly, however, treatment outcomes are assessed in terms of collateral behaviors such as social stability and employment.

Individual treatment programs may include multiple levels of care and encompass a gamut of options such as detoxification, inpatient and outpatient treatment, partial hospitalization, and residential [Page 687]settings. Rehabilitation is generally targeted at treating both physical and psychological dependence. Thus, treatment may integrate medical and/or behavioral therapy.

There are approximately 13,000 treatment programs in the United States. Many of them are funded by local, state, and federal governments. Many nonprofit organizations have developed to deliver SUD treatment. In addition, private entrepreneurs have developed programs operating on a for-profit basis. Public policy supportive of treatment took a major turn in 2008 with the passage of the Wellstone-Ramstad Act requiring parity in group health insurance coverage for the treatment of SUDs and mental disorders. This act, effective in 2010, was designed to address the deterioration or disappearance of coverage for these treatments that had resulted from the implementation of private “managed care” plans beginning in the 1980s. While parity coverage requirements have the potential for dramatic increases in treatment access and utilization, implementation of the legislation remains to be observed.

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