Individuals who complete the very early stages of a treatment program for a substance use disorder are often very tempted to make the determination that their struggle is over.
This is particularly true of individuals who complete a detox program. Detox simply assists a person in negotiating the withdrawal process and avoiding relapse during this very acute recovery stage. Detox must be followed by more intensive therapy, but even this is not enough. The majority of professional sources indicate that some type of aftercare is necessary following the acute stage of recovery in order for an individual to be successful on a long-term basis.
The term aftercare in the context of substance use disorder treatment refers to additional treatment that an individual participates in once they complete a formal program. Aftercare is needed for those who participate in either inpatient or outpatient treatment programs.
Types of Aftercare
The basic elements of an aftercare program include the following:
- Therapy: Therapy consists of formalized treatment programs based on psychological principles that are delivered by a trained, licensed, mental health professional, such as a psychologist, counselor, social worker, etc. There are a number of different schools of therapy that can be applied to substance use disorder treatment. The most common form of therapy used in addiction treatment is Cognitive Behavioral Therapy. Therapy can be delivered on an individual basis (one client with one therapist), a group basis (more than one client treated by one therapist in the same session), or performed in a combination of individual and group sessions. Group therapy can consist of a number of different types of groups, ranging from marital or couples therapy to formal groups.
- Social support groups: These groups are not run by professional mental health workers but by individuals who are suffering from the same issue. The most well-known of these groups are 12-Step programs, such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, etc. Other types of social support groups that are not based on the 12-Step program exist.
- Medical management: This type of aftercare treatment involves care from a psychiatrist or addiction medicine physician. These individuals typically do not engage in much formal psychological therapy or counseling but instead administer medications to help the individual control cravings for drugs and alcohol and to address other issues, such as depression.
- Treatment for co-occurring disorders: An individual who is diagnosed with a substance use disorder and some other mental health disorder at the same time is classified as having co-occurring disorders. Because individuals are more successful in recovery if both diagnoses are treated at the same time, specialized care is used for these individuals.
- Complementary therapies: Other types of aftercare treatments that do not fit neatly into the above categories can include mindfulness meditation programs; participation in physical activities designed to assist individuals with substance use disorders, such as yoga, martial arts, etc.; and other types of complementary and alternative forms of intervention, such as wilderness therapy, music therapy, art therapy, etc. Most of these programs are designed to work with formal treatment programs, and they are not typically considered to be standalone aftercare treatments.
Discussion of aftercare include any of the above approaches or combinations of any of the above.
Does Aftercare Work?
The vast majority of sources, both older and more recent, such as information provided by the Substance Abuse and Mental Health Services Administration (SAMHSA), indicate that overall relapse within the first year to two years following initial recovery occurs in nearly 50 percent of all individuals trying to recover from substance use disorders.
The National Institute on Drug Abuse (NIDA) reports that relapse rates for substance use disorders are similar to the relapse rates observed for other medical conditions that have a significant behavioral component to them (e.g., hypertension or diabetes). Again, these relapse rates are generally around 40-50 percent. Thus, many sources suggest that relapse is often part of the process of getting better, and individuals learn from relapses and move on to become stronger in their recovery. However, the goal of substance use disorder aftercare treatment is to avoid relapse.
A number of research studies support the notion that being the engaged in an aftercare program can significantly reduce the risk of relapse for individuals in recovery and can also be extremely important in guiding individuals who do relapse to get back on track in the recovery program. The long-term success rate for individuals who engage in an aftercare program compared to those who do not indicates that being in an aftercare program is advantageous to long-term recovery.
- Early findings, such as those reported in the book Treating Drug Problems, indicate that the duration of treatment is a good predictor of success. The earliest findings indicate that remaining in formal treatment three months or longer is associated with better outcomes.
- Long-term studies of treatment that were performed in the 1990s indicated that the treatment was effective for the majority of individuals who used aftercare programs. The majority of these individuals stopped using alcohol or drugs eventually and experienced less frequent relapse issues when engaged in treatment following acute rehab. Almost 90 percent of individuals who were able to maintain their participation in aftercare programs for periods of two years or more were found to be relapse-free 10 years later. However, individuals who did not engage in aftercare treatment relapsed at rates between 50 percent and 90 percent.
- Meta-analytic reviews are often the preferred form of evidence when ascertaining the overall effects of a particular treatment paradigm. This is because meta-analysis combines the results of a number of different studies looking at the same form of treatment. The overall trend in the effects of numerous studies is much more convincing evidence than the results of any single research study. Meta-analytic studies support the notion that aftercare treatment is effective in avoiding relapse compared to no treatment at all.
- A 2008 meta-analytic study reported in The American Journal of Psychiatry investigated the effects of aftercare treatment for individuals with cannabis use disorders, opioid use disorders, cocaine use disorders, and poly-substance use disorders compared to no treatment at all. The effect sizes for the studies used in this meta-analysis indicated that the aftercare treatment was more effective than no treatment. Effect sizes ranged from small (about 0.2 for polysubstance abuse) to large (about 0.8) for cannabis use disorders. The effect size refers to the magnitude of the effect of a number of studies investigating a particular issue. The results indicate that the studies looking at recovery for these forms of substance abuse reported that aftercare treatment was indeed effective in avoiding relapse.
- A 2014 meta-analytic study in the journal Substance Use and Misuse provided evidence that mindfulness-based aftercare therapies were effective at reducing consumption of alcohol and drugs in individuals. Mindfulness-based therapies are based on a combination of Eastern philosophy and Cognitive Behavioral Therapy.
- A 2014 study in the Journal of Substance Abuse Treatment found modest effects for aftercare programs overall in avoiding relapse in individuals with substance use disorders.
- The average length of time that must pass before someone is considered to be in remission from a substance use disorder is significantly longer than often believed. Remission refers to an individual who has recovered from the majority of the major symptoms that are associated with a disorder or disease. A recent meta-analytic study published in the journal Drug and Alcohol Dependence indicated that substance use disorders were best defined as long-term disorders as opposed to more acute disorders. In the studies in the meta-analysis, remission was not considered to occur in up to 50 percent of individuals with substance use disorders until after an average of 17 years of abstinence. Longer follow-up treatment or aftercare treatment periods were associated with higher rates of remission. This is consistent with the notion that aftercare programs are important in long-term abstinence.
Thus, consistent with the claims of all of the major organizations involved in the research and treatment of substance use disorders, aftercare programs significantly increase the chances of recovery.
A 2011 study in the journal Substance Use and Misuse suggested that individuals who are satisfied with their withdrawal management treatment and who have been in withdrawal management treatments for longer periods of time are more likely to engage in aftercare than individuals who do not remain in these programs long enough to sufficiently go through the withdrawal process and/or are not satisfied with their acute rehab treatment. Thus, one key to getting an individual into a needed aftercare program is to ensure that their residential withdrawal management program is satisfactory and lengthy enough to develop a foundation for recovery.
Finally, SAMHSA reports that four specific factors are also associated with successful long-term recovery from a substance use disorder:
- A sense of health that includes abstinence from alcohol or drugs, dealing with medical issues, and healthy lifestyle choices
- Having a stable place to live
- Having some type of purpose, such as work, school, family involvement, volunteering, etc.
- Having relationships and strong social support networks that provide the individual with support and hope
Conclusions
Based on the research evidence, it is clear that participation in aftercare programs significantly increases the probability that one will be successful over the long-term in recovery from a substance use disorder. Substance use disorders are considered to be chronic disorders and as such require longer participation in treatment.