As we’ve discussed above, addiction involves persistent drug-induced adaptations in the brain systems responsible for controlling behaviors that are necessary for proper integration into complex social systems. Hence, therapeutic interventions should take this into consideration and create incentives for the substance abusers to engage and stay in treatment including strategies that help strengthen social ties with family and community. Social interactions are powerful reinforcers that can provide the addicted individual with alternatives to help counteract the perceived high-reward value of drugs.
An important consequence of the longterm brain adaptations is that most addicted patients will require a long period of treatment, during which relapse is likely to occur, which should be considered a predictable setback and not a failure of the treatment. This also explains why the best treatment outcomes are reported by programs that offer continuity of care for a 5-year period (McLellan et al., 2008
). In addition, chronic drug abuse has recently been recognized to be associated with impaired self-awareness (including interoceptive or bodily awareness), which manifests as compromised recognition of disease severity and/or the need for treatment, but that has frequently been interpreted as denial (Goldstein et al., 2009
). This in turn contributes to the low rates of treatment initiation and high-dropout rates.
According to the 2010 National Survey on Drug Use and Health (NSDUH) (SAMHSA, 2010
), in 2009, 22.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem, but only 2.6 million received treatment at a specialty facility. This means that 20.9 million persons who needed treatment did not get it. The reason for such high undertreatment rates is instructive: the vast majority of addicts did not even perceive a need for treatment and among those who did admit needing treatment over half either didn’t make any effort to seek it or were unable to procure it. The persistence of such a vast SUD treatment gap—the result of a combination of inadequate infrastructure and lack of interest—is a great concern because it continues in spite of the availability of effective interventions.
The disconnect that exists between treatment needs and access is even more apparent in the context of criminal justice system populations. The fact is that most prisoners (80%–85%) who could benefit from drug abuse treatment do not receive it (Mumola and Karberg, 2006
). This is a missed opportunity because integrating treatment into the criminal justice system would enable us to provide treatment to individuals who otherwise would neither seek nor receive it, and it has been shown to improve medical outcomes and reduce recidivism particularly when maintained throughout the critical postrelease period (Chandler et al., 2009
). This is because returning to a neighborhood awash with so many drug-associated cues can trigger powerful cravings and relapse to compulsive drug-seeking behaviors. This is further compounded by the systemic difficulties and stressors these individuals face when reintegrating into society, including that of finding a job while under the shadow of a criminal record. This is vividly illustrated by the following letter.
I am writing as the mother of a crack addict. My daughter has been an addict for 12 years. She is the mother of 4 children all of which she has lost parental rights to. She has been in prison most of the 12 years, and had many programs, doing well in what was offered during incarceration. When she is released from prison, she is always hopeful for success…. She is immediately faced with 4 major challenges: getting a place to live, finding a job, transportation, and obtaining continuing recovery treatment…. Now she just got [out] of jail 3 weeks ago, went through what I just described above, and went back on the streets. She was broke and shop-lifting, and now will go back to jail, do the program for probably the 10th time, and be released again the same way. There are many like my daughter, so addicted they will end up dead.