Substance Use Disorder Treatment: What Works
Substance use disorder, commonly called addiction, is continued use despite harm, with craving, loss of control over the amount used, and a brain reward system that has reorganised itself around the substance.
Also called: Addiction, Substance dependence, Drug addiction, Alcohol use disorder.
ICD-10 F10-F19 · ICD-11 6C40
Make using lighter. Make the rest of life heavier.
Willpower alone rarely does it. Willpower was never the whole problem.
Treatment that works does two things at once. First it weakens the pull, often with medicine. Second it builds up everything else. That means rewards, skills, people, and a reason to get up. Recovery usually takes more than one attempt, and every attempt still counts.
WHERE TREATMENT STARTS
It depends on the substance, and on the person
For opioids, NICE, the National Institute for Health and Care Excellence, and the World Health Organization recommend methadone or buprenorphine. These medicines cut the risk of death by more than half, for as long as a person stays on them.
For alcohol, there is a supervised detox first if it is needed. Then come medicines such as acamprosate or naltrexone, alongside talking therapy.
For stimulants like cocaine, no approved medicine exists yet. The strongest evidence is for giving rewards for clean tests. Doctors call this contingency management.
Some things help with every substance. Talking therapy. Help with housing, work and health. And support from people who have been through it themselves.
THE BALANCE
Tip the scale.
Below is a balance with two sides. On the left sits using. On the right sits everything else in the person's life.
Early in recovery, using outweighs everything else. That is not a failure of character. It is what the reward system has been trained to feel.
Treatment works on both sides at once. Medicine takes weight OFF using. Everything else adds weight to the other side. Add the weights and watch the beam tip.
Then press "A hard day". Stress and old cues make craving surge. The question to ask is the real one. Not "can I tip it today?" but "will it still hold when the day is bad?"
Add weights to the right-hand side. Then press "A hard day" and see whether the balance holds.
Using
Everything else
A hard day
Pull toward using
9
5
3.2
drug
-3.5 — Medicine for craving
Takes weight off using
Rewards
alt
3 — Rewards for clean tests
Something to win, today
Therapy
alt
1.5 — Talking therapy
Halves the pull of a hard day
People
alt
2.5 — People who have been there
Company that is not using
Purpose
alt
2.5 — Work, study or a purpose
A reason to get up
A home
alt
2 — A safe place to live
Somewhere away from the old cues
Using outweighs everything else. Add something to the other side.
Closer now. The other side is getting heavier.
It tips. The rest of life now weighs more than using does.
A hard day. Stress, an old friend, the old street. Craving surges.
It held. The weights you added were still there when it mattered.
It tipped back. That is a slip, not the end. Every weight is still on the scale.
No single weight did this on its own. Medicine made using lighter. Everything else made life heavier. Hard days still come, and they always will. Recovery means the balance holds more often than it does not. It gets built one weight at a time.
Early on, using outweighs everything else in a person's life.
Medicine can take weight off using. Rewards, people, work, a safe home and therapy all add weight to the other side.
On a hard day, craving surges. With enough on the other side, the balance holds. A slip is common, and it does not undo what has been built.
The weights here are invented to show the idea. Real treatment is planned with a doctor or a key worker, and it changes with the substance and the person. Stopping some substances suddenly is dangerous without medical help.
THE OPTIONS
What else has evidence
Most people do best with more than one of these at the same time.
Opioid medicines
Methadone and buprenorphine calm craving and withdrawal. They do it without the high and the crash. They are the single biggest protection against dying of an overdose.
Alcohol medicines
Acamprosate eases craving after someone stops. Naltrexone makes drinking less rewarding. Both are used far less than they should be.
Talking therapies
Cognitive behavioural therapy (CBT) and relapse prevention teach you to spot triggers and plan for them. Motivational interviewing helps people find their own reasons to change.
Why harm reduction is treatment too
Naloxone, clean equipment and drug checking keep people alive long enough to recover. Nobody recovers after dying of an overdose. Meeting people where they are is not giving up on them.
IF YOU ASK FOR HELP
What actually happens, in order
No one has to hit rock bottom first.
It starts with a conversation, either with a doctor or with a local drug and alcohol service. Many services let you refer yourself.
Then comes an honest look at what is used, and how much. The person also says what they want. That might be to stop completely, or to cut down.
If withdrawal is likely, a safe plan is made for it. Sometimes that means medicine, or a short stay somewhere.
Then comes ongoing support. That can include medicine, therapy, a key worker, and often a group of people going through the same thing.
A plan for slips is made in advance, so that one bad night does not turn into a lost year.
OVER TIME
How well it works
It works better than its reputation suggests. It rarely works in a straight line.
Relapse rates here are about the same as for other long-term illnesses. High blood pressure and asthma are two examples. In those illnesses too, symptoms return when the treatment stops.
Staying in treatment for longer is linked to better outcomes. Leaving opioid treatment is a high-risk time for overdose.
Most people with a substance use disorder eventually recover. Many of them need several attempts to get there.
COMING OFF
Slowly, and not too soon
Medicines for addiction are often taken for years. That is completely fine.
Methadone and buprenorphine work best as long-term treatment. Coming off them is a choice made with a prescriber. It is done slowly, and when life is stable.
Tolerance falls quickly after someone stops opioids. Many overdoses happen when a person uses their old amount after a break.
The other side of the scale matters as much after treatment as during it. That means people, purpose, and a plan for hard days.