The Impact of Supplemental Services in Treatment of Substance Abuse

The impact of Supplemental Services in Treatment of Substance Abuse, Including a Case Study and Treatment Recommendation for Hydrocodone AbuseUniversity of Colorado at DenverKrista Smith/CPCE 5280

Abstract

Statistics and information on Hydrocodone abuse are discussed in this paper. Research that supports the inclusion of supplemental services such as therapy, and medical treatment in addition to traditional substance abuse treatment is also included. A fictitious case study involving hydrocodone use will demonstrate my personal style of therapy from a systems perspective as well as integrating the supplemental services as suggested by the research. Recommendations for preventing substance abuse and for further research in this area will also be included.

Introduction

It is a common stereotype to think of an addict as an abuser of heroin or someone who smokes crack. Occasionally, this stereotype is built upon to include a vision of a homeless person or a prostitute who lives on the street or in a debilitated crack house. In reality, this population represents only a portion of the people who are addicted to or abusing drugs in the United States today. Many addicts are "every day" people who live in the city or suburbs, have children and jobs. Their drug of choice may not be cocaine, but rather a prescription drug that may have been provided by their doctor for a legitimate reason.

This research paper examines the abuse of the generic drug Hydrocodone, an ingredient in many prescribed pain killers such as Vicodin. A description of Hydrocodone abuse and statistics will be followed by a fictitious case study that highlights the particular details of one situation involving Hydrocodone abuse. My personal style of therapy will be discussed and a treatment plan integrating my therapy with the research supported inclusion of supplemental services will follow. Further recommendations for study conclude this paper.

What is Hydrocodone

Hydrocodone, which is from the same family of drugs as heroin, is commonly prescribed to assist patients recovering from surgery. It falls under the drug class Opiate Analgesics, and according to experts, these drugs do not need to be abused for years for them to be lethal (Kuhn, Swartzwelder, & Wilson, 2003). Hydrocodone is also commonly used to alleviate the symptoms of people experiencing chronic back pain. If prescribed and taken properly, it can bring a lot of relief to patients, but if crushed and snorted or swallowed, the intensity of the drug increases making it powerfully addictive (Gavin 2005). According to the U.S Drug Enforcement Administration, due to a rise in reported incidences involving the drug's abuse, Hydrocodone is now the nation's most abused prescription drug (Hasemyer & Cantlupe 2004).

A Growing Problem

In general, research indicates that prescription drug abuse is occurring at an increasing rate (Hasemyer & Cantlupe 2004; Kuhn, Swartzwelder, & Wilson, 2003; Gavin, 2005). A recent anonymous survey result deemed that one in every 10 high school seniors had used the painkiller Vicodin in the last year without a doctor's orders or prescription (Gavin 2005). Add this number the already staggering statistic of 75 million Americans who are suffering from chronic pain, a common ailment that often receives a prescription for a Hydrocodone product. The high number of Americans suffering from chronic pain for which Hydrocodone is commonly prescribed indicates the possibility of a very high percentage of Americans using and being prescribed Hydrocodone. This statistic highlights the precarious situation of many people in the United States having access to and possibly abusing Hydrocodone that was originally prescribed to them (Sullivan 2001).

Unlike other substance addictions such as marijuana or cocaine, some people who abuse Hydrocodone were prescribed to take it to alleviate their undesirable symptoms. This places them in a unique situation with their relationship with the drug. Many times an addiction begins with the patient taking the medication as prescribed by the doctor. The patient receives relief and sometimes a euphoria which leads the patient to continue seeking out the drug to produce that feeling (Sullivan, 2001). If the doctor is not careful with follow up and/ or monitoring, the patient may increase the dosage, or take it longer than necessary and eventually become addicted to the very medication that s/he was prescribed to take.

A Popular Drug

There is reason to be concerned about the abuse and availability of medications containing Hydrocodone. According to IMS Health, as cited in Sipkoff's research (2004), the number of Hydrocodone-related prescriptions grew from approximately 80 million in 1999 to 100 million in 2002. This means that four times the number of prescriptions was written for medications that contained hydrocodone than for the popular narcotic OxyContin in 2002(Sipkoff, 2004). According to the Drug Enforcement Administration in 2001, prescribed medications containing Hydrocodone became "the most commonly diverted category of controlled pharmaceuticals (Sipkoff, 2004)." One DEA official stated publicly that Hydrocodone is one of the most abused drugs in the nation and that DEA is seriously considering reclassifying medications containing the drug in order to reduce abuse and trafficking. (Sipkoff, 2004).

The DEA also reports that " In the 1990s, there was a 500% increase in the number of emergency department visits attributed to hydrocodone abuse, to an estimated 19,221 visits by 2000 (Sipkoff, 2004). The DAWN report found that opioid pain relievers accounted for more than 119,000 emergency department mentions, or 10 percent of all the entire drug mentions in drug abuse-related emergency department visits in 2002 (ADAW, 2004).

Treatment of Substance Abuse

Substance Abuse treatment effectiveness varies widely across programs (McLellan et al. 1994; McLellan, Woody, et al. 1997). The focus on research of the best treatment for substance abuse focus on treatment providers enhancing traditional addiction services such as individual and group counseling, self-help groups with additional services that address a client's psychosocial and medical needs such as general mental health care, vocational and job placement services, legal assistance, and routine medical care (Durkin, 2002). Past research shows that substance abuse treatment programs may follow a researched treatment plan, but they often fail to meet the standards that the research suggested (Price, 1997).

Incorporating Supplemental Services in Treatment

For various reasons, access to and use of some of these critical supplemental services may be declining over time (D'Anno & Vaughn, 1995; Etheridge et al. 1995). Therefore it is essential to first identify what are the most influential supplemental factors and then what can be done to increase the likelihood that those who are seeking treatment receive these services (Durkin, 2002). It is an unfortunate reality that even if something is found to be highly effective in treatment, if it is cost prohibitive, the client will likely not receive the services, or if received, must pay a high price for them.

One influential factor that seems to have a great impact on how many supplemental services an addict can receive is managed care. Researchers suggest that managed care's focus on keeping costs down and services to a minimum tend to limit supplemental services even when they have been found to be effective in treating substance abuse (McCarty, 1996; Etheridge et al., 1997). This is unfortunate due to the results from several studies that show a positive relationship between substance abuse clients' receiving supplemental services and their treatment success.

In studies of methadone treatment, more successful outcomes occurred when the standard methadone treatment was enhanced with supplemental care (McLellan et al., 1993). These services include on-site access to medical, psychiatric, employment and therapy services (McLellan et al., 1993). Another study found that psychotherapeutic interventions were effective in assisting the client in overcoming various types of substance abuse (Woody et al., 1987). A study that focused on publicly funded outpatient treatment that included both methadone and nonmethadone programs concluded that clients in a "treatment as usual" group did not do as well as clients that were involved in a program that was enhanced with case management and provided several contractual arrangements with social and medical service providers (McLellan et al., 1998).

Other researchers found similar positive results among substance abuse clients and supplemental services. One group concluded that the positive relationship between successful treatment outcomes and supplemental services exists in a variety of treatment settings (Ball and Ross, 1991). Even though supplemental services seem to have positive results in client treatment among substance abusers, determining the exact nature of this relationship among supplemental services and positive outcomes is difficult.

In an attempt to determine the exact nature of the positive relationship between the treatment of substance abuse and supplemental services, some researchers suggest that supplemental services may influence an individual's decision to participate (Ball and Ross, 1991). Others claim that supplemental services are a major component in an individual's decision to remain in treatment (Simpson, Joe, and Brown, 1997). If the services are specifically tailored to the client's individual needs, then an even greater positive relationship was found between supplemental services and positive treatment outcomes (Fiorentine, Nakashima, and Anglin, 1999).

Kirk Broome and colleagues (1999) determined that the availability of social and public health services increases client confidence in outpatient treatment. They found this to be true even for clients who possessed low levels of need. This information added to the evidence that clients who remain in treatment past "recognized thresholds" (90 days for outpatient drug free programs) have significantly better treatment outcomes (Simpson et al., 1997; Durkin, 2002).

This research suggests that the role of supplemental services in positive outcomes is that these services assist the client in staying in the treatment for the recommended amount of time, therefore increasing his/her chance of a successful outcome. This association between lengths of stay and supplemental services was the focus of another group of researchers. The length of the stay may determine the availability and the amount of exposure to particularly helpful supplemental services that ultimately are critical to the successful treatment of the client's substance abuse.

Individuals with chronic substance abuse problems generally show high levels of psychosocial and medical need (Etheridge et al., 1997) that appear significant enough to interfere with their progress through treatment (Durkin, 2002; Ball and Ross 1991; McLellan et al. 1994). If this is the case, and supplemental services are able to respond to and address these needs, then it could be suggested that this too is another factor in the positive relationship between supplemental services and positive treatment outcomes. In conclusion, programs that match a client's individual needs to their supplemental services are more successful in reducing drug use and improving well-being among substance abuse clients. (McLellan et al. 1994; McLellan, Grissom, et al. 1997; Durkin, 2002).

Personal Approach

I consider myself to be an integrative therapist that focuses on family systems theory as a basis for treatment. I believe that people do not function in life independent of one another. If a person is going to change, then the entire system needs to change as well. If only one person (the identified patient) is focused on as the person who needs to change then I believe it will be much harder for that person to create and sustain positive change. The other family members need to realize and understand their impact on the identified patient so they can support the healthy changes in his/her life.

As a family systems therapist, I must also note that I do not focus on the identified patient. I believe that it is very possible that the person cited as being the reason for the family to be in therapy is often reacting to the personalities and actions of fellow family members and is actually not the individual who needs therapy the most. If this issue is not addressed and explored in therapy, and only one person continues to be the focus of the therapy sessions, then I believe that long-term change is very unlikely.

Case Study

Cheryl is a 32-year old stay-at-home mother of two who has been abusing Hydrocodone (in the form of Vicodin) for three years. She was initially prescribed the drug to assist her in the recovery of her caesarean section after the birth of her twin boys, now almost three. She states that at first the Vicodin treated the pain of her surgery and she took it as directed. She soon noticed that if she took a little more than prescribed that she was calmer and better able to care for her children.

Cheryl soon grew dependent on the drug and became irritable and depressed if she was not taking it. She switched doctors several times and confesses to currently seeing four doctors who are all prescribing her Vicodin for the relief of Fibromyalgia. She states that she looked up that condition on the internet and began presenting the symptoms to her new doctors so she could get the drug. Now she is noticing that her tolerance for Vicodin has increased again and at her current rate of abuse, she either needs to get a way to get more Vicodin or she needs to be treated for this addiction.

She states that she feels overwhelmed at caring for the boys all by herself all day. Her husband has chosen a position at work that has him traveling out of state often so sometimes she spends an entire week at home alone with her sons. She has no family close by and she also states that she misses the social contact that she received when she was a sales rep in the fashion industry before she had children. She states that motherhood is not as fulfilling to her as she had hoped and that she often fantasizes about putting the boys in daycare a few days a week so she could go back to work.

Treatment Plan

I would first commend Cheryl on seeking out help with such a powerful addiction. I would spend the first session listening empathetically to her situation while refraining from sounding like an expert or pointing out her inconsistencies. In my first session, my first priority would be to join with Cheryl and lay down a foundation of trust. The next thing I would recommend is for Cheryl to find and attend a 12- step program of Narcotics Anonymous. I would do this so she could see what it's all about and determine for herself where she is at with her addiction, and what she ultimately would like to do to treat it. I would tell her that this fellowship would provide her with support and encouragement as well as the opportunity to learn how others are coping with beating this addiction.

Since I am not an addictions specialist and have minimal training in the area, I would focus my attention on alleviating some of Cheryl's stressors in her life that may have led to the abuse. I would work with Cheryl on developing healthy coping strategies for stress such as exercise, a new hobby or helping her find an activity that she always wanted to do but didn't. I would also encourage Cheryl to reevaluate her husband's work situation. If a change is not possible for him, I would encourage Cheryl to seek out reliable childcare for at least one day a week so she could have a break from the children and time to work on herself.

In addition to my work with Cheryl on her family system, I would also refer Cheryl to an addictions specialist who could help Cheryl cope with the difficulties of coming off of the drug Hydrocodone. I would work in partnership with this person to ensure that our treatment plans are on the same page. I would want Cheryl to have the latest and most comprehensive information and help that she could have on breaking this addiction and I believe that an addictions specialist could assist her in this area.

Following the recommendations of the research on supplemental services I would also incorporate several of those that I think would be most beneficial to Cheryl. First, I would discuss possibly returning part-time to some work outside of the home to increase her social activity as well as give her some accomplishments outside of her home. I would encourage her to visit with a career counselor that specializes in mothers returning to work outside of the home. If Cheryl does not wish to return to work outside of the home, then I would suggest she take one day a week for herself and place the boys in childcare. I would stress the importance of her getting a break, and also the importance of social activity.

In addition to the 12-step program, the time outside of the home for herself, I would also encourage Cheryl to visit with a doctor to discuss the possible medical side effects she could experience when off the drug. I would encourage her to discuss with her doctor anything else that my assist her in recovery, whether it be acupuncture, massage or a visit with a nutritionist to develop a healthy eating plan to further encourage this healthy lifestyle change.

Overall, I would remain a strong supporter in Cheryl's' road to recovery. I would be supportive and encouraging, but also confrontational when necessary. Even though I am not an addictions specialist I can be a powerful influence in her recovery by keeping her on task and assisting her in changing her environment as much as possible to support her recovery. I believe through therapy with me to change her family system and environment, taking time for herself without the children with an enjoyable or social activity, regular therapy with an addictions specialist as well as regular attendance to Narcotics Anonymous meetings, Cheryl has the best chance for recovery from this addiction.

Even though not every therapist subscribes to my theoretical orientation as a therapist who basis treatment on systems theory, there are several key components in my treatment plan that they could apply. No matter what theoretical orientation a therapist has, expressing empathy and creating a safe place for the client to express his/her feelings and share experiences is extremely important. Without these things, the client may never progress. Other therapists may not focus on Cheryl's family system and environment from the same viewpoint that I do, but I think that many would consider an absent husband and the demands of 24 hour childcare to young twins to be a deterrent to recovery.

Other therapists could also benefit from incorporating supplemental services. By using other services and professionals outside of one's expertise, the client receives a comprehensive treatment for addiction that improves chances of recovery. Most therapists would likely agree that joining a supportive fellowship such as Narcotics Anonymous where Cheryl would receive support and accountability could only help her chances in succeeding in beating her addiction. Even if they are not systems based therapist like me, I believe that other therapists should consider the other factors and relationships in Cheryl's life that may hinder her success in treatment or make overcoming her addiction especially difficult for her.

Recommendations

After reviewing the case study and research on addiction and supplemental services, it is important to ask, what else can be done to prevent and discourage the abuse of prescription drugs such as Hydrocodone products? One solution involves the better tracking and monitoring of prescription drugs to curtail abuse. A recent U.S. General Accounting Office report showed that it was relatively easy to get Vicodin and hydrocodone without a prescription from Internet pharmacies, many of which are located overseas (Gavin, 2005). This internet availability presents a unique problem in tracking the abuse of Hydrocodone. If people are able to purchase the drug from an overseas pharmacy and have it shipped to their home, this transaction could occur without anyone knowing about it.

Some solutions are being presented to assist in curtailing the availability of Hydrocodone. One example of this is a prescription-monitoring program. These programs currently exist in only about one third of the United States, and they help identify doctors who are writing unneeded prescriptions. This program also can identify people who "doctor-shop" in order to obtain the maximum amount of pain medications either by not disclosing how many doctors they are seeing, or by creating or exaggerating symptoms of pain. (Sullivan, 2001). If a universal tracking system were put into place, a doctor could have the patient checked in a database to determine whether or not s/he is an abuser. Since doctors really have no other way of knowing if the patient is shopping around to many doctors to get the prescription filled, this might provide that opportunity. Although a tracking system could provide some deterrence to the abuse, it is by no means a solution completely within itself.

Another solution proposed by the Drug Enforcement Administration is to reclassify medications containing Hydrocodone as Schedule II narcotics. This action would make these drugs, including even cough suppressants, more difficult to prescribe and complicated to dispense (Sipkoff, 2004). Although it is uncertain if restricting the drugs in this manner would only hurt those who truly need the drugs since addicts and abusers can get Hydrocodone over the internet.

Another method of reducing abuse of prescription drugs is for doctors to apply restraint in prescribing addictive drugs such as Hydrocodone. Alternative therapies such as biofeedback or acupuncture could be explored as an option instead of relying on potentially addictive drugs. When hydrocodone products are deemed to be the appropriate and best course of treatment for the patient, then it is necessary that the doctor has regular check ups and monitors the patient, so h/she might notice the problems or early warning signs of addiction. Also, a doctor could spend time with the patient and possibly even provide some literature on the drug's ability to become addictive if misused or taken improperly.

Another solution involves simple things someone can do at home. It may seem obvious but it is important to keep drugs that can be abused out of the medicine cabinet. For a short-term prescription, or a temporary cough medicine, throw it out if there's some left after symptoms are gone. This simple act removes the temptation of abusing a drug after it has served its initial purpose.

Recommendations for Further Research

Often, research neglects to include marginalized populations. This leaves some important questions that should be addressed in order to fully understand the nature and treatment of substance abuse and addiction. What are the multicultural aspects in substance abuse? Would populations outside of the Anglo-Saxon male profile be better served in alternative treatment settings? Are there other reasons why marginalized populations are abusing these drugs that differ from the reasons that were previously given by middle class Causations? It would seem obvious that an upper class housewife abuses Hydrocodone for different reasons than a 22-year-old impoverished Gay male. If the reasons are different, than the treatment needs to be supplemented to address all the pertinent issues.

Another area of research to be examined further are what types of supplemental services are most effective, and are they universally effective across broad groups, or are the best results individually tailored? Also, the cost benefits of supplemental services should be researched. If determined to be most cost effective in the long-run, it is possible managed care would be more likely to cover them.

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