Harvard Mental Health Letter, Oct 1995
v12 n4 p1(4)
Treatment of drug abuse and
addiction. (part 3)
Full Text: COPYRIGHT 1995 Copyright by President and
Fellows of Harvard College. All Rights Reserved
This is the third of three parts. In Parts I and II we described
the man varieties of drug abuse treatment and
began an analysis of outcome research. In this part we conclude that
analysis; we also comment on the disease concept of addiction, the
goal of abstinence, the use of of coercion, spontaneous recovery,
and the future direction of drug programs.
Among addiction treatments, methadone maintenance stands out as
particularly cost-effective. According to a 1993 report prepared by
the Alcohol, Drug Abuse, and Mental Health Administration the
average cost to society over a six-month period was $21,000 for an
untreated addict, $20,000 for an imprisoned addict, and $1,750 for
methadone maintenance. Residential treatment is five to six times as
expensive, and outpatient drug-free treatment lacks the major virtue
of methadone programs -- their low dropout rate. Most research
suggests that methadone programs work better when they also supply
counseling, medical care, and psychiatric services. Programs are
less successful when they keep doses low, do not allow patients to
take the drug home, or discharge them because of temporary relapses
and missed appointments.
Therapeutic communities (TCs) will never be available for the
great majority of drug abusers, since participants must volunteer to
segregate themselves from society for months or even years. Some
critics question whether these programs are worth the cost. No
cost-benefit analyses and few controlled studies are available.
Graduates of therapeutic communities do well, but dropout rates are
high. There is only one study in which TCs were compared directly
with other treatments. Four hundred heroin addicts were assigned
randomly for six months to one of two methadone maintenance clinics
or one of three residential programs. Patients taking methadone and
those in the long-term residential program had a better outcome (as
measured by drug use and crime rates) than those placed in a
short-term residential community. Little is known about the
effectiveness of TCs for alcohol and cocaine addicts.
Although 12-step self-help groups are now almost universally
accepted, at least as a supplementary treatment, dropout rates are
high and clear evidence of effectiveness is difficult to come by.
According to AA's own surveys, about 50% of members remain for three
months. One review has found that 88% drop out within a year.
According to another review, 35% to 40% of active members report
abstinence for less than one year, 25% to 40% for one to five years,
and 20% to 30% for five years or more. The only two available
controlled studies found no long-term differences between problem
drinkers sent to AA under a court order and those not assigned to
any treatment, but men directed to AA by the legal system are
obviously not typical members. The benefit-to-cost ratio for 12-step
groups is considered favorable, since they cost almost nothing.
Evidence about the effectiveness of other methods is sparse. In a
controlled study conducted in Finland, inpatient chemical dependency
treatment proved superior to an alcohol and drug ward in a
psychiatric hospital with a more informal program. Several studies
have found inpatient and day hospital treatments to be equally
effective for alcoholics; one has found inpatient treatment more
effective. Inpatient programs are losing popularity because of their
expense, and sources of insurance are drying up. In two controlled
studies, cognitive-behavioral relapse prevention training proved to
be no more effective than informal group therapy. A third study
found a modest difference, and a fourth found that behavioral
treatment was more effective than a 12 -step program. Investigators
supported by the National Institute on Drug Abuse are pursuing
controlled research on cognitive therapy for relapse prevention in
cocaine addicts. Several studies suggest that psychotherapy and
family therapy make methadone maintenance more effective.
Not enough evidence
Critics have questioned the usefulness of the outcome research
and the conclusions drawn from it. They say that the value of most
forms of alcohol and drug treatment is unproved because the studies
have too many limitations, including insufficient time for follow-up
(six months is common, although several years may be necessary to
guarantee recovery), a high dropout rate (the patients who remain
might be those who would improve anyway), and a 40% rate of recovery
without treatment. Other complications are created by the presence
of psychiatric disorders, the many patients lost to follow-up, a
lack of independent evaluators, use of unreliable information
provided by drug users themselves, insufficient description of the
severity of the drug problems, and inconsistent or uncertain
standards for measuring the outcome.
There are few controlled studies with truly random assignment to
treatments or no treatment -- which is a problem, because addiction
is a disorder in which the act of seeking treatment might be
regarded as a sign of improvement. Since drug abuse and addiction
are often episodic, it may be important to know the patient's
condition for years before treatment, but that information is often
unavailable. Since different kinds of treatment produce similar
modest results, there is some suspicion that they are all placebos.
Critics cite studies suggesting that, at least in milder cases of
drug dependence, elaborate therapies are no more effective than
being told to read a brief self-help manual or listen to a half-hour
talk about the harm resulting from one's alcohol or drug use.
Although advocates of drug treatment admit the limitations of the
available research, they say that it is sufficient to demonstrate
the value of the programs.
Is it disease?
An issue that arises repeatedly is whether the purpose of drug
programs is to treat a disease or simply to help people whose lives
have gone wrong. The disease model is often identified with chemical
dependency treatment, medications, and 12-step programs. The model
of addiction as a learned habit or life problem is usually
associated with cognitive and behavioral therapy. Many advocates of
the disease model regard drug dependence as a chronic brain
malfunction -- a chemically induced disorder of the brain's reward
or pleasure center that may cause lasting physiological changes
associated with an alteration in neurotransmitter functioning. They
say that labeling addiction as a disease is useful because it
removes some of the stigma and guilt, making it easier for a patient
to seek and accept help. They add that addiction is obviously
dangerous to physical and mental health. Critics of the disease
model believe it is used to ignore or explain away underlying
problems. They say that thinking of drug abuse as a disease reduces
confidence, promotes moral irresponsibility, and unnecessarily
limits the choice-of-solutions.
To some extent this argument is about words. Addictions might be
regarded as diseases for some purposes and not others. Even people
who mistrust the disease concept admit that genetic and biochemical
factors are involved in drug abuse. Even those who prefer the
disease model recognize that a behavioral modification or a
spiritual crisis might lead to recovery. A destructive habit can be
changed in many ways, by anything from a counteracting chemical to a
political reform that eliminates an underlying social condition.
The debate about the disease concept of addiction overlaps a less
theoretical and more familiar argument in which abstinence is pitted
against controlled use. This issue is raised only in connection with
alcohol, since controlled use of illicit drugs is socially
unacceptable as a goal of treatment. If alcoholism is primarily a
brain disorder caused by the presence of a chemical toxin,
abstinence seems to be the only plausible solution. If it is part of
a larger problem affecting all aspects of a person's life, the
drastic measure of abstinence might be unnecessary in cases where
other ways can be found to change that life.
According to advocates of abstinence, much as alcoholics might
want to return to the days when drinking gave them more pleasure
than pain, they almost always find that moderation has become
impossible for them. Any impression to the contrary, abstinence
supporters add, results from insufficient follow-up. Advocates of
moderation respond that the illusions are on the other side: only a
few alcoholics, they say, ever become permanently abstinent. They
claim that an ideology of abstinence dominates addiction treatment
in the United States but not in the rest of the world. As a
practical matter, many patients treated for drug and alcohol abuse
reject abstinence. On the other hand, aiming for abstinence could be
the best way to achieve moderation, just as a speed limit causes
even the people who exceed it to drive more slowly Although the
evidence is disputed and there is no consensus, most experts believe
that controlled use is a reasonable goal only when the alcoholism is
not severe. Some think that after long abstinence and other changes
in their lives, certain alcoholics can return to moderate drinking.
Using force
Coercion in drug treatment is both a therapeutic and a political
issue. At any given time at least half of clients and patients in
drug and alcohol programs are under legal pressure of some kind.
After being arrested for drunk driving, disorderly conduct, drug
possession, domestic violence, prostitution, and other crimes, they
are assigned to treatment before trial or required to accept
treatment as a condition of probation or parole. A few therapeutic
communities are located in prisons and discharge their participants
to community-based counterparts after release. In fact, since our
society has chosen coercion as the first line of defense against
most addictive drugs, the most common alternative to forced
treatment of drug abusers is not voluntary treatment but force
without treatment.
Many clients of drug programs are first-time offenders, often
people with stable jobs and families who do not believe they have a
problem or need help. They may be either openly hostile or
deceptively submissive, and in either case resentful and
uncooperative with any genuine effort at change. Many specialists
think it makes little sense to force treatment on them when so many
people who want it cannot get it. But others believe that the
justice system can be used as a sort of
involuntary outreach program, a way to help people who would
otherwise never acknowledge their need. Advocates of coerced
treatment say that even modest success would make the effort
worthwhile, given the magnitude of the problem.
Most studies have found that drug abusers under legal coercion
benefit from treatment no more and no less than anyone else. The
most extensive evidence comes from a 12-year follow-up of addicts
committed to treatment in the California Civil Addict Program in the
early 1970s. People who remained in this program for five years,
first as residents and then in the community, were compared with
similar addicts released after a short time because of procedural
errors. During the period of commitment, treated addicts had much
lower rates of heroin use and criminal activity. The gains were not
permanent: three years after discharge addiction reached
pre-commitment levels, and after seven years there was no difference
between the two groups. Similar civil commitment programs in New
York had higher dropout rates and were considerably less effective.
The distinction between coerced and voluntary treatment is less
clear than it may seem, since so many drug and alcohol abusers seek
help only under external compulsion. An alcoholic or addict who
enters a treatment program to "get them off my case" may be
referring to family members or employers as well as police and
judges. For example, some people with drug problems come into
treatment through employee assistance programs after supervisors
notice that their work is deteriorating. Drug and alcohol abusers
often must be under some social pressure at the start to seek help;
later they may see the need for it more clearly for themselves.
On their own
There is a high rate of recovery among alcoholics and addicts,
treated and untreated. According to one estimate, heroin addicts
break the habit in an average of 11 years. Another estimate is that
at least 50% of alcoholics eventually free themselves, although only
10% are ever treated. One recent study found that 80% of all
alcoholics who recover for a year or more do so on their own, some
after being unsuccessfully treated. When a group of these
self-treated alcoholics was interviewed, 57% said they simply
decided that alcohol was bad for them. Twenty-nine percent said
health problems, frightening experiences, accidents, or blackouts
persuaded them to quit. Others used such phrases as "Things were
building up" or "I was sick and tired of it." Support from a husband
or wife was important in sustaining the resolution.
Alcoholics and other drug abusers often need help of so many
kinds that it is unclear whether drugs
are the primary problem. Some evidence is contained in Lee
Robins's remarkable study of heroin addiction among soldiers who
fought in Vietnam (see The Harvard Mental Health Letter, December
1994). Two or three years after their return, despite the extremely
high rate of addiction in Vietnam, veterans were no more likely to
be dependent on heroin than comparable civilians, unless they had
had drug problems and antisocial tendencies before joining the armed
forces. Even men who used heroin again after their return to the
United States almost always found their addiction fairly easy to
break. The few Vietnam veterans who needed treatment for heroin
addiction in the United States, on the other hand, had just as high
a relapse rate as most treated addicts. Robins concluded that many
people who are described as heroin addicts in order to fit the mold
of a drug treatment program have so many, other problems, most of
them originating before the addiction, that the label is little more
than a convenience, and "treatment of
drug abuse" is
an inadequate description of their needs. Other research suggests a
questionable correlation between the amount of drugs or alcohol a
person uses and the severity of the associated psychological and
social problems. Given this situation, it seems natural that there
is so much doubt about which drug users need which treatment when.
No clear answers
The future of drug and alcohol treatment is uncertain; the
problems are great and the needs are many. In society's attitudes
toward drug abusers, resentment contends with sympathy. There is
some reluctance to expend resources on people who may show little
gratitude and who seem to have brought their troubles on themselves.
At present not enough addicts seek help on their own, and too many
drop out, finding treatment easier to demand than to accept.
Classifying drug abusers and matching them to programs is difficult.
Programs are adequately held accountable for results, and doubts
persist despite evidence of the effectiveness of treatment. Public
drug programs often suffer from the burdens of inadequate staff and
unreliable funding. Waiting lists are long. The average length of
treatment, less than four months, is generally thought to be
insufficient.
In 1988 the National Institute on Drug Abuse commissioned a study
of drug problems by a committee of the Institute of Medicine, a
branch of the National Academy of Sciences. Its proposals, published
in 1990, provide as good a picture as any of the prospects for drug abuse treatment in the United States. The committee
recommended more outreach to adolescents, pregnant women, and
mothers with children, and more emphasis on community programs as
opposed to hospitalization. It suggested that programs should
combine resources to make it easier for several options to be
provided for each patient or client. The report also proposed more
use of advocates, case managers, or expediters to help people
negotiate the system and find the programs they need. Other
recommendations were better monitoring of the performance of drug
programs, more careful cost-benefit analysis, more attention to the
factors that cause drug abusers to accept treatment, and more
research on the neurochemistry of drug dependence.
The Harvard Mental Health Letter (ISSN 0884-3783) is published
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For Further Reading
Marc Galanter and Herbert D. Kzeber, eds. Textbook of Substance
Abuse Treatment. Washington, D.C.: American Psychiatric Association
Press, 1994.
Dean R. Gerstein and Hendrick J. Harwood, eds. Treating Drug
Problems, Volumes I & II. Washington, D.C., National Academy
Press, 1990.
Stanton Peele and Archie Brodsky with Mary Arnold. The Truth
About Addiction and Recovery. New York: Simon and Schuster, 1991.
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