Providing treatment requires an understanding of the natural history of recovery from addiction. Recovery from drug addiction and/or alcoholism is a long-term process that often requires multiple attempts and many behavioral changes. Most people relapse several times before achieving long-term abstinence, regardless of whether the drug of abuse is nicotine, cocaine, heroin or other addictive substances. People who do achieve long-term abstinence can, in stressful situations, relapse after years of abstinence. The long-term relationships between family physicians and patients and their families may make a significant difference in supporting a patient's recovery efforts.

In discussing options with the patient, the physician should recommend a comprehensive treatment plan. Some patients may resist those choices, often preferring a less intensive approach. Others may refuse all outside help, insisting that they can "kick the habit" on their own - which represents another form of denial. In either case, negotiation with the patient is more effective than a protracted discussion. Sometimes, it is possible to enter a contract in which the patient agrees to undertake a more intensive approach if the first set of treatment options - those preferred by the patient - fails. Regardless of which approach the patient chooses, the physician should be supportive.

Brief Interventions
Illicit drug abusers may sometimes respond to brief interventions such as those used for smoking or alcohol abuse. In some cases, this approach may successfully modify the patient's behavior by itself. In many others, failure may be used as a springboard to convince the patient of the need for more extensive treatment.

The goal of a brief intervention is to provide the patient with information about the disorder and suggestions to help modify his or her behavior. The physician should stress the possible negative consequences of the patient's drug use, both currently and in the future. Giving the patient educational materials may help reinforce these points. Then the physician can make a specific recommendation for cutting down or stopping. The patient can return in a month to report progress. If the patient has been able to control the habit sufficiently to reverse the negative consequences, no further treatment may be necessary. However, if the patient cannot stay within the agreed-upon limits, a more intensive therapeutic strategy is warranted, such as participation in a 12-step program or other self-help groups.

Detoxification
Many drug-dependent patients can safely undergo withdrawal as outpatients. This approach is less expensive and less disruptive of the patient's life than inpatient therapy. Moreover, it allows withdrawal to be completed in the same environment in which the patient must continue to live, work and remain abstinent.

To qualify for outpatient detoxification, the patient must clearly agree to abstain from using any mood-altering agent, other than those prescribed by the treating physician. He or she must also agree to participate in a treatment program. The choice of program depends on personal finances and community resources. During the first few days, the patient also needs a sober and responsible family member or friend who will encourage participation in a program, watch for serious signs of withdrawal, assist with medications, get the patient to the physician's office and dispose of any alcohol or drugs in the patient's home.

The physician should evaluate the patient every day until he or she has started a treatment rehabilitation program and the risk of withdrawal is minimal. This interval may range from three days for alcohol abuse to 10 days for methamphetamines, opioids and cocaine. Physician monitoring is essential on the weekend, when the risk of relapse is greatest. No more than a two- to three-day supply of medication should be dispensed at any visit, to preclude the misuse of medication and possible overdose.

If the criteria for outpatient therapy are not met, inpatient or residential therapy may be indicated. This has the advantage of placing the patient in a protected setting where access to substances of abuse is restricted (although not necessarily eliminated). The withdrawal process may be quicker and safer because the patient can be monitored more closely and treatment can be more finely tuned.

Hospital treatment is more likely to be needed for withdrawal from sedative drugs, such as alcohol, barbiturates and benzodiazepines. Withdrawal from these drugs can be life-threatening. Hospital treatment is also indicated for patients who have a very high tolerance for the substance of abuse or who developed seizures, delirium or psychosis during a previous withdrawal. Medical indications for inpatient therapy include a history of recent head trauma or cerebrovascular accident, acute abdominal pain, jaundice, liver failure, electrolyte imbalance, pneumonia, sepsis, dehydration, AIDS, arrhythmias, angina, ischemic heart disease, hypertension, severe respiratory disease and age greater than 65 years.

Hospitalization is almost never indicated for opiate detoxification, which is best accomplished through an outpatient methadone program. Hospital recovery programs of fixed stays of 14 to 28 days have been overutilized, with scant evidence of benefit for any but a few carefully selected patients.

Safe detoxification (outpatient or inpatient) is labor-intensive, and physicians often find it difficult to obtain commensurate reimbursement. That is why many state and local governments have created specialized facilities or programs for low-income patients who need these services. Each state receives "block grant" funding from the Public Health Service to help meet these needs. A call to the local public health department, state drug abuse and/or mental health agency or the national hotline will lead the family physician to whatever services are available locally. Admission can often be facilitated by the family physician who agrees to continue seeing the patient for other medical problems in coordination with the public program. In areas where there are no other services, the family physician may be the only qualified provider, and telephone consultations may become vital. The patient's family and peers can be used as a therapeutic network to join the patient at intervals in therapy sessions.

Hospital Treatment
With admission to the hospital for withdrawal, the patient should undergo an evaluation, including urine drug screens, to determine whether he or she has been using other drugs not previously mentioned. Detoxification is initiated to withdraw the patient from the substance of abuse and to restore cognitive ability. No other treatment goals should be addressed until both goals are achieved.

At that point, a major goal of therapy is to help the patient identify the consequences of his or her experiences and to understand the risks of relapse. Another goal is to address emotional issues such as hopelessness and despair over the seemingly inevitable progress of the addiction and grief and remorse associated with comprehension of past behavior. Barriers to recovery are identified, including internal barriers such as the patient's personality or personal resources and external barriers such as the home or work environment. The patient is protected from self-destructive or other violent behaviors.

Because dishonesty, violence and risk-taking are survival skills in active addiction but become self-destructive in recovery, new sets of behaviors are introduced. Twelve-step and other recovery programs describe a set of new behaviors that allow the addict to deal with the consequences of the past and the problems of the present. Involvement with groups such as Alcoholics, Narcotics or Cocaine Anonymous, Rational Recovery or Women for Sobriety should begin during hospitalization and be maintained after discharge; decreasing use of such support groups often leads to relapse.

Short-term hospitalization is useful as a means of facilitating entry into long-term treatment. By itself, however, hospitalization has no demonstrable effect on long-term recovery.