The confusion about what is research based treatment, what are custodial counseling or spiritual services and what is harm reduction have make many patients seek the wrong help; for example: 

1.                  A hospitalization and/ or emergency room services are usually the most costly and less effective level of treatment and has being abused by most patients making a revolving door effect and increasing cost of services.  This make the medical insurances to cover  each year less benefits/ days of treatment and to refuse the reimbursement of payment for more effective and less costly  treatments.

2.                  A "home" with custodial and religious counseling is an important help specially for homeless people but is not a substitute for scientific treatment and, if used alone, have shown low effectiveness on long term for most patients

3.                  Self help and 12 steps groups are essential for support and maintenance but are not a substitute for treatment and have shown low effectiveness for the majority of patients if used alone.  As part of a treatment and as a help to develop a maintenance support network are excellent  and very important for our society.

4.                  The local and the federal government agencies does not educate the people about the differences in services (if they follow or not NIDA’s recommendations) and the academic qualifications/ experience or preparation of the therapists of each program implying the wrong and dangerous idea that “all treatments or helps are made equally effective for any patient” and the differences are the costs or if it is ambulatory or not.

5.                  The propaganda in all the media of miracle medicines (“medicalization”) or detoxification as a substitute for psychiatric interdisciplinary treatment that is contrary to what the research have shown move people to spend their money in false remedies and not in more cost effective ones.   Office based treatment, medicines, detoxification or controversial therapies (as acupuncture for SD) used alone are a harm reduction approach.  If they are not as part of a comprehensive treatment program these interventions have also shown to be ineffective and costly for most patients.

6.                  Most patients are in denial and wont accept their treatment unless they are motivated or receive pressure from their family.  Many patients become chronic and deteriorated each year at younger ages due to lack of effective treatment on time before deterioration.  Chronic deteriorated patients are more resistant to any scientific treatment and need a harm reduction approach to reduce ( if possible to refrain) the damage to them and to society..

7.                  The universal spirituality, human values and/ or spiritual counseling is an important part of any comprehensive psychiatric treatment but is not equal to a particular denomination of religion or faith.  Spiritual counseling is not considered a research based therapy but a complement to therapy.  There is evidence in Puerto Rico of repetitive obstruction of new legislation for the improvement of research based services by some influential community based organizations that receive money for treatment but at the same time are offering very limited or no treatment at all. .  Some of these organizations receive very insufficient funds and  see impossible for them the payment of professionals for a psychiatric interdisciplinary treatment teem professionals.  Others don’t have any interest in offering these scientific services and see them as unnecessary spend of the money that they receive for their “spiritual treatment”.  

“In general, intensive programs (also known as enhanced outpatient services) are more expensive than standard outpatient because they provide more frequent services, case management, or more counseling hours, requiring more staff.  Several studies have found and concluded that enhanced outpatient services, although more expensive than standard services, yield better outcomes and are more cost effective.  In other words, the extra cost of enhanced serviced yielded a lower cost per unit improvement in various outcomes. Another study across 99 treatment programs found that the costs per abstinent case and per reduced drug use case were much lower for outpatient clients ($6,300 and $2,400 respectively), than for residential ($14,900 and $6,700) or inpatient ($15,600 and $6,100) clients.”  This last costs doesn’t account the impossibility of part time working or studying in a patient during treatment in  residential programs.  This limitation and extra costs doesn’t exist in outpatient or enhanced programs.

B. Compendium of expert consensus: “Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs”;  A Treatment Improvement Protocol TIP 43,U.S. Department of health and human services, 2005

This important document emphasizes in the necessity of The Psychiatric Interdisciplinary Team Approach directed by an addiction psychiatrist:

“The complexities of treatment planning for patients who receive Medication Assisted Treatment require a multidisciplinary treatment team, the composition of which varies with OTP resources and the population being treated.” “The consensus panel recommends that part of the treatment team consist of a physician trained in addiction psychiatry, who provides leadership, health care, and medical stabilization; conducts detailed evaluations of the patient; monitors medications; and provides needed substance abuse interventions when indicated.”…

C. Principles of Drug Addiction Treatment; A research-based guide National Institute on Drug Abuse, National Institutes of Health; October 1999

This important book summarizes what research had found that work in addiction treatment in 13 principles. 

At Alternativas we follow not only the 13 principles for effective treatment of NIDA but also make the family (important support people) part of the treatment program.  We do diagnosis and treatment of all psychiatric disorders present in the patient and not only addiction problem using a real bio-psycho-social-spiritual model.  The spirituality in our program does not include particular religious concepts but universal healthy values/attitudes  elaborating the concept of a Higher Power and Recovery.

Our treatment program includes the following:

1. Scientific evaluation of each patient including initial interview by addiction psychiatrist, social worker, structured interview (Addiction Severity Index), Psychological and addiction testing (MMPI-2, CAGE, MAST, CRAFT, LOCUS PAS and others) basic laboratory work out, periodic urine toxicology and breathalyzer.

2. Multiple integration of pharmaco-therapy: ambulatory detoxification, Buprenorphine induction, psychiatric medication when needed.

3. Multiple integration of psychotherapies not only for addiction but for all psychiatric disorders diagnostized:

1. Individual including contingency management, cognitive, motivational, behavioral, dream interpretation, meditation, medical hypnosis.  This is about 3 hours each week in the intensive phase to one hour each two weeks in regular ambulatory phase

2. Group including psycho educational and educative; is 2-3 hours each  week to one each week in regular ambulatory phase.

3. Family therapy including marital therapy; is 2-3 hours each  week to one each week in regular ambulatory phase

     4. Referral and integration to Support Groups and to primary psychiatric services (to the referring psychiatrist)  for long term aftercare after the intensive phase of treatment.

We also follow the best up to date research treatment manuals, assessments and procedures and adapt them to our population.  We have also incorporated optional adjunctive treatments such as neurofeedback, technology of brain wave induction by sound, meditation, reflexology, vitamin/nutrients supplements and medical hypnosis.

The program begins with evaluation of the patient and family members to assess if the patient will benefit from IOP program or need a more intensive (Therapeutic community) or less intensive treatment approach (regular outpatient treatment).   If the patient is accepted for treatment the intensive part of it may take from 3-6 months followed by 1-3 more months of regular ambulatory treatment.  After our treatment; the patient is referred back to his previous psychiatrist,  therapist and support groups for long term maintenance and relapse prevention (aftercare).