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.
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