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Harvard Mental Health Letter, August 1995 v12 n2 p1(4)

Treatment of drug abuse and addiction. (part 1)

Full Text: COPYRIGHT 1995 Copyright by President and Fellows of Harvard College. All Rights Reserved
Drug abuse and alcoholism are complex psychiatric disorders with obscure causes, and the best approach to treatment is uncertain at every stage. Diagnosis is not easy, recovery is precarious, and relapse is common. Although many useful treatments have been developed, there is no reliable, lasting, inexpensive cure.
It helps to begin with some definitions. According to DSM-IV, the present edition of the American Psychiatric Association's diagnostic manual, the symptoms of substance dependence (a synonym for addiction) fall into three classes: (1) Compulsion or loss of control: taking more than you think you should and unsuccessfully trying to cut down or stop; spending too much time under the influence or recovering from the effects. (2) Tolerance (constantly needing more for the same effect); withdrawal reactions, and using the drug to avoid or interrupt withdrawal reactions. (3) Impairment: using the drug despite serious ill effects, physical, psychological, or social; and preoccupation with the drug to the exclusion of other pleasures and activities. Substance abuse is distinguished from dependence by the absence of tolerance and definite loss of control, and by a greater emphasis on social consequences. The distinction is neither precise nor fixed for any given person.
The three types of drug most commonly abused, separately and in various combinations, are: (1) alcohol and sedative-hypnotics; (2) opioid narcotics, chiefly heroin; (3) stimulants, chiefly cocaine and amphetamines. Nicotine, another highly addictive and widely used substance, presents different problems and is not generally discussed in the same contexts as other abused drugs.
Although everyone knows that substance abuse is common, the number of cases is difficult to judge because of imprecise definitions and unreliable findings. The best evidence, from household surveys, suggests that 5% to 10% of American adults have a serious alcohol problem, and 1% to 2% have a serious illicit drug problem. Two thirds of these drug abusers are men, and most are in their twenties or thirties. Of the million or more prisoners and parolees, probably the majority are drug or alcohol abusers.
Undoing the addiction
The first step in treatment is recognizing and then acknowledging the need for help. Friends, family members, and doctors may remain silent for fear of being intrusive or having to assume responsibility. Sometimes they see the problem as moral rather than medical, or believe they should avoid a stigmatizing label. Drug abusers and alcoholics themselves often deny, conceal, rationalize, minimize, and blame others. Most of them do not seek treatment, and even those who want some help may be ambivalent about the drug habit or unwilling to change it. This resistance complicates the already serious difficulties of treatment. Many physicians and mental health professionals find confrontation and conflict with patients distasteful and are reluctant to treat people who may seem both demanding and ungrateful.
Drug abuse is the product of a complicated pattern of mutual influence involving the addictive substance, individual psychology, and the social environment. Accordingly, a wide variety of treatments has been developed, from the biochemical (use of agents that block drug effects) to the religious (encouraging repentance and spiritual renewal). There are several major types of treatment programs. Methadone maintenance is widely used for opiate addicts. Residential therapeutic communities (TC's), originally designed for opiate addicts, are now available for people dependent on other illicit drugs as well. Inpatient chemical dependency treatment is used mainly for alcoholism. Outpatient drug-free treatment, a miscellaneous category, includes a variety of programs with little in common, from drop-in centers to outpatient TC's with various forms of psychotherapy, counseling, and referrals to social services. The clients in these programs are often abusers of a variety of illicit drugs and alcohol (polydrug abusers). Most programs also cooperate with twelve-step selfhelp groups like Alcoholics Anonymous, Cocaine Anonymous, and Narcotics Anonymous. Finally, many people are treated for problems that include drug and alcohol abuse in private individual or group psychotherapy.
Detoxification (withdrawal of the drug under supervision) is sometimes required as a first step in the treatment of addiction to opiates, alcohol, and other sedatives. Hospitalization is usually unnecessary except in some severe alcohol and barbiturate addictions, where the withdrawal reaction may include delirium or potentially fatal seizures. Sometimes a long-acting drug is substituted for a shorter-acting one with similar effects (diazepam for alcohol, methadone for heroin) to slow the pace and ease the symptoms of withdrawal. Medications for insomnia may also be needed. Detoxification is a prerequisite for treatment, not a treatment in itself. Most detoxified addicts soon return to the drug, and some go through withdrawal only to reduce their tolerance and resume using the drug at a lower dose.
Fighting fire with fire
The most popular treatment for heroin addiction is substitution of oral methadone, another opiate. More than 110,000 people are enrolled in methadone maintenance programs in the United States. Taken once a day, methadone prevents withdrawal symptoms and stabilizes the lives of addicts. They generally become less depressed, less active as criminals, and more capable of maintaining a job and family life. Some are better able to control their use of alcohol, cocaine, and marihuana as well. After several months, a patient may be allowed to take the methadone home and visit the clinic less often. (A recently approved longer-acting variant of methadone, levo-alpha-acetylmethadol -- LAAM -- needs to be taken only once every 72 hours.) Methadone is physically safe, and patients can continue to take it for many years without uncomfortable or toxic effects. Their urine is tested for drugs at random intervals and psychotherapy, vocational counseling, and other services may be offered as well.
This treatment is controversial and subject to restrictions because it substitutes one addiction for another. Methadone programs are strictly regulated by the Department of Justice, the Department of Health and Human Services, and the states to prevent diversion of the drug into the illicit market. Many programs use dosages regarded by experts as inadequate, and most programs give a high priority -- some say unnecessarily high -- to eventual withdrawal from methadone.
Apart from detoxification and methadone maintenance, drugs are used in the treatment of drug abuse for two other purposes: counteracting or blocking the effects of other drugs, and relieving symptoms caused by addiction or associated with it. One such drug is disulfiram (Antabuse), which reduces the desire to drink by preventing the normal metabolism of alcohol and causing the accumulation of a nauseating toxic by-product. The narcotic antagonist naltrexone reverses the effects of a heroin overdose and blocks the action of opiates at nerve receptor sites for 48 hours or more. Taken regularly, it prevents craving and allows an addict to live without fear of succumbing to the temptation of heroin. The main side effect, liver toxicity, usually occurs at doses higher than those needed for addiction treatment.
Patients are usually unwilling to take naltrexone for more than a few months. Persuading them to continue may be difficult; they must be committed to change and in need of protection only against momentary lapses. Naltrexone is most useful for well-motivated middle- and upper-class addicts, and it serves mainly as a way to gain time to engage them in other kinds of therapy. Recent research indicates that naltrexone also reduces craving for alcohol and the pleasure of drinking, possibly because alcohol and opiate dependence share a neurochemical mechanism in the release of endorphins. Buprenorphine, another synthetic drug, is known as a narcotic agonist-antagonist because it has some of the neurochemical properties of both methadone and naltrexone.
There is no specific and reliable antagonist for stimulatnt drugs. Researchers, who suspect that naltrexone may dampen all pleasures of intoxication, are now testing it on cocaine addicts as well. Other drugs that have been used to reduce craving for cocaine and relieve the discomfort of withdrawal are lithium, tricyclic antidepressants, MAO inhibitors, anticonvulsants, and the dopamine agonists amantadine and bromocriptine, which act at the same nerve receptors as cocaine. Several studies suggest that tricyclics may prolong abstinence for at least a few weeks to months. Lithium may be helpful for cocaine abusers with bipolar disorder, and the oral stimulant methylphenidate (Ritalin) may aid addicts with attention deficit disorder. Fluoxetine (Prozac) and other selective serotonin reuptake inhibitors are also under study, because cocaine alters the effects of serotonin as well as dopamine. Researchers are now trying to develop new drugs that selectively block the activity of cocaine at various types of receptor.
Group efforts
The first residential therapeutic community was Synanon, founded in 1958. Today there are more than 500 such programs in the United States, accommodating 10,000 to 15,000 patients. These communities are mainly designed for poorly educated people whose lives have been consumed by drug abuse and crime. Seventy-five percent have an arrest record, and most are unemployed. Nearly half have been treated at least once before they enter the TC, often under some legal or other pressure. The community provides a substitute family in which strict rules of behavior, enforced through rewards and punishments, are supplemented by individual and group therapy and encounter groups. The regimen is demanding, outside influences are discouraged, and patients are closely monitored. Residents do their own housekeeping and management, assuming more responsibilities and privileges in an internal hierarchy as they show improvement. They learn from staff members who are former addicts. Drug abuse is regarded as a disease of the emotions that requires a transformation in thinking, feeling, and behavior leading to the development of self-reliance, a sense of responsibility, and a work ethic. Patients usually remain in residence for six to 12 months and leave by stages over a period of a year.
Therapeutic communities have become more flexible in their practices. Originally developed for heroin addicts, they now accommodate other drug abusers. Some employ mental health professionals, allow the use of behavior therapy and medications, or provide help for families (seminars, support groups, psychoeducation). Sometimes a TC is one component of a center that also offers outpatient treatment, methadone maintenance, and other services. Shorter programs with less emphasis on confrontation and hierarchy are being introduced, as well as separate programs for adolescents and for mothers with children.
Another type of residential program is chemical dependency treatment (sometimes called "Minnesota model," after the location of the hospital regarded as its prototype). Chemical dependency programs differ from TC's in the kind of patient they attract, the length of stay, and the attitude toward professional control. Management and housekeeping are in the hands of paid professionals and workers. Patients, who are often middle class, alcoholic, and privately insured, stay for a month, usually on a ward in a medical or psychiatric hospital or a specialized drug dependence unit. They are counseled by recovering addicts and alcoholics under the direction of a team of medical and mental health professionals. The program includes individual and group therapy, lectures, self-help meetings using twelve-step principles, and family education. Aftercare, which may last for three months to two years, can mean anything from an occasional telephone call to weekly group therapy. These programs now accommodate about 10,000 patients in the United States.
Inpatient treatment in a TC or chemical dependency unit has the advantages of providing medical supervision while allowing patients to reflect on their lives in a setting where alcohol and drugs are difficult to obtain. A corresponding danger is that they will be insufficiently prepared for the dangers and temptations of the world outside.
Many drug treatment programs urge their participants to join Alcoholics Anonymous or one of its many twelve-step imitators. There are now more than 50,000 chapters of AA in North America and many more all over the world. According to one recent estimate, about 40% of members are referred by drug treatment facilities and 34% by other members; 27% join on their own. By 1989, about half of AA members had illicit drug as well as alcohol problems. The twelve-step process involves admitting powerlessness, seeking help from a higher power, invoking that power by meditating or praying, making a moral inventory, confessing wrongs, begging forgiveness, making amends, and carrying the message to others. Abstinence is the goal, to be sought, as the saying goes, "one day at a time."
In meetings, members tell their personal stories and discuss various topics including each of the twelve steps. Each member has a sponsor who provides help and comfort in crises. In principle, members are supposed to attend meetings every day, at least in the beginning. Research suggests that having a sponsor, being a sponsor, and carrying the message to others are especially important for success. Twelve-step programs are most attractive to people with severe addictions who feel guilty, have religious concerns, and need strict rules to live by.
Alcoholics and drug abusers who are put off by the religious emphasis of AA, its insistence on abstinence, or its intense focus on the drug may prefer another kind of mutual aid group. There are some which modify the twelve steps and translate them into a more secular language: acknowledging inability to control alcohol or drug use, recognizing the need for change and for help in attaining that change, understanding the need for honest self-evaluation and working with others to maintain it. Such groups as Rational Recovery, Men and Women for Sobriety, and Secular Organizations for Sobriety differ from AA in not insisting on abstinence or cathartic confessions. Instead of endorsing the idea of powerlessness and the need for a higher power, they concentrate on clarifying and correcting self-defeating thoughts. They try to avoid the kind of permanent dependence on self-help meetings that they say AA encourages.
RELATED ARTICLE: For Further Reading
Marc Galanter and Herbert D. Kleber, 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.