Harvard Mental Health Letter, Sept 1995
v12 n3 p1(3)
Treatment of drug abuse and
addiction. (part 2)
Full Text: COPYRIGHT 1995 Copyright by President and
Fellows of Harvard College. All Rights Reserved
This is the second of three parts. In Part I we described
detoxification, methadone maintenance, therapeutic communities,
12-step groups, and other proposed treatments for drug abuse. In
this part we discuss individual and group psychotherapy, behavioral
and cognitive therapy, and the treatment of drug abusers with
psychiatric illnesses and HIV infection.
Individual psychotherapy is a component of many drug programs,
but rarely the primary treatment. Psychotherapy is often
time-consuming and expensive, and many people with drug problems
reject it. Addiction is difficult to treat if it is regarded mainly
as a symptom that will disappear when an underlying problem is
resolved. Besides, effective psychotherapy is nearly impossible
while drug or alcohol abuse continues. In a person whose commitment
to change is tenuous, psychotherapy may even cause anxiety and
frustration that heighten the danger of relapse. Individual therapy
is probably most useful for people with serious psychiatric symptoms
as well as a drug or alcohol problem. It can also be used to begin
drug abuse
treatment in a private and confidential
setting. Supportive therapy providing sympathy, encouragement, and
advice is usually best in the early stages; insight into the past
and the relationship with a therapist may be helpful after the
patient attains sobriety.
By contrast, group therapy in various forms is a treatment of
choice in most drug programs. It may be based on psychodynamic,
cognitive, behavioral, or other principles. A leader or
psychotherapist establishes rules, screens and prepares members for
admission, educates the patients about drugs, and tries to ensure
that the discussion remains open, relevant, and mutually respectful.
Personal relationships within the group serve as a microcosm of
social life. Patients give up chemical pleasures for the rewards of
companionship, helping themselves while helping others. The group
provides a sense of belonging and a source of friendships that are
not exploitative. Realizing that they are not alone, patients feel
less despairing and ashamed. By watching and imitating others, they
clarify distorted ideas about themselves. The support of the group
sustains an individual resolution to give up alcohol or drugs.
Some programs also provide support for the families of drug
abusers. They are shown how to help the addict and are introduced to
self-help support groups like Alanon. If there is any evidence that
the family's behavior is inadvertently encouraging drug abuse (if,
for example, family members are assuming the drug abuser's
responsibilities), the techniques of family therapy may be brought
into play. In a variant of family therapy known as network therapy,
employers, friends, and neighbors may also be involved. Members of
the network meet regularly and are summoned in emergencies to
discuss with the psychotherapist ways of preventing imminent
relapse.
Changing behavior
Many drug programs make use of methods that fall into the broad
category of behavioral and cognitive treatment. These approaches are
based on models derived largely from the treatment of phobias and
compulsive rituals. Drug abuse is regarded as behavior that is
encouraged by certain ways of thinking or learned through certain
patterns of conditioned association and reinforcement (reward). If
these patterns are changed, the abusive habit can be modified or
unlearned. Patients are exposed to the situations, thoughts, and
feelings that cause drug abuse while efforts are made to prevent the
usual response. An increasingly popular program called relapse
prevention training consists largely of various combinations of
behavioral and cognitive techniques.
There are many such techniques. Contingency contracting is a way
of altering reinforcement patterns; for example, a patient agrees to
forfeit money in case of relapse or make it available for use only
after abstinence. Behavioral self-control training shows patients
how to monitor and limit their drug and alcohol consumption. They
are taught to identify and record the situations and feelings that
cause drinking or drug use -- physical sensations, social pressure,
conflict with others, bad feelings, the lure of good times. They
learn how to avoid some, cope with others, and find alternative
responses where possible. At first they may have to be separated
from external influences (such as certain friends or places) that
provoke drug abuse. Then they can gradually expose themselves to
more and more risky situations for a series of small gains and
increased control. Each success is expected to heighten a bracing
sense of self-efficacy, or confidence in the ability to resist.
Cognitive therapists try to alter half-conscious and half-formed
self-defeating beliefs that make life without the addiction seem
unbearable ("I cannot tolerate anxiety"; "I need something to
overcome my shyness") or provide excuses for succumbing to
temptation ("I deserve a drink after a hard day"). Patients are made
aware of these beliefs and shown how to test them through regular
homework. They are taught general strategies for solving problems
and shown how to achieve pleasure or a feeling of accomplishment
without drugs.
A major complication in the treatment of addictions is the
presence of other psychiatric disorders that create the need for a
dual diagnosis (see Harvard Mental Health Letter, August and
September 1991). In the recent Epidemiologic Catchment Area survey
of the American population, 39% of alcohol abusers and 50% of people
with other drug problems also had another diagnosis; the most common
were anxiety disorders, mood disorders, antisocial personality, and
borderline personality. The rate of dual diagnosis is even higher
among people actually being treated for addictions.
The implications for treatment depend partly on which set of
symptoms is considered more serious or more fundamental. It is often
difficult to tell whether the psychiatric disorder or the drug
problem comes first. Self-medication sometimes makes addicts of
people with major mental illnesses (depression, bipolar disorder, or
schizophrenia). Certain personality disorders are also conducive to
drug abuse. But psychiatric symptoms -- including acute psychoses,
secondary mania and depression, and rebound depression after
stopping drug use -- can also occur as biochemical, psychological,
or social consequences of drug abuse. (If the symptoms no longer
persist a month or two after abstinence, the psychiatric disorder is
probably not independent.) The two types of disorder may also have
common causes in heredity, upbringing, or social circumstances.
Eventually they exacerbate each other, perpetuating a vicious cycle
and making it difficult to distinguish between effects of drug abuse
and the symptoms of such disorders as major depression, borderline
personality, and antisocial personality. Partly for that reason,
addiction itself was once mistakenly classified as a personality
disorder.
First things first
Almost all experts agree that the drug problem must be treated
before any therapy can be effective. Although evidence is limited,
the choice of a program may depend on the presence of other
psychiatric disorders; for example, antisocial personalities are
considered better candidates for cognitive or behavioral treatment
than for self-help groups or insight therapy, which may be more
useful for patients who are seriously anxious or depressed.
Medications should be used with great caution in treating insomnia,
anxiety, or depression during drug or alcohol intoxication and
withdrawal.
In principle all patients should be evaluated and treated for
both kinds of disorder. But in practice the institutional
arrangements for treatment of alcoholism and other drug addictions
are largely separate from those designed for other psychiatric
disorders. The two systems have different funding sources and
licensing procedures; they are poorly coordinated and often do not
share information. People with addictive problems are often made to
feel unwelcome in programs for the treatment of psychiatric
disorders, as are patients with psychiatric disorders in drug abuse
programs. Patients with dual diagnoses may be shuttled between the
two and never properly treated. Some receive so many conflicting
messages that they become lost and confused and drop out.
This situation may be changing. Drug abuse programs have been
using more psychiatric methods and employing more mental health
professionals. Some programs for the mentally ill have added drug
and alcohol treatment. Individual case managers may also be useful
in helping patients to negotiate the systems. The National Institute
of Mental Health has recently granted funds to states for
community-based demonstration projects on the treatment of dual
disorders with various combinations of behavioral and cognitive
techniques.
A new twist
The AIDS epidemic has created another terrifying complication in
the treatment of drug abuse. Today in
the United States about 30% of new cases of HIV infection result
from intravenous drug use, either directly through needle sharing or
indirectly through sexual activity and the birth of children. Since
the infection often causes neurological symptoms that can be
confused with effects of intoxication, withdrawal, and habitual drug
use, careful diagnosis and urine testing are necessary for any
intravenous drug user. Drug abuse interferes with the care of AIDS
patients and makes it difficult for them to comply with recommended
medical regimens. The present system accommodates only about 20% of
intravenous drug abusers, and for most of them one round of
treatment is insufficient. Sexual behavior under the influence of
alcohol and drugs is even more difficult to change. Needle exchanges
and AIDS education in drug programs are important for these
patients; they may also need new arrangements that combine the
services of social workers, physicians, and psychiatrists.
Is drug abuse treatment
effective, and which treatments work best for which patients? These
questions are becoming crucial because public funding may depend on
the answers. Most experts are convinced that treatment improves the
lives of drug addicts and alcoholics by various measures, including
drug consumption, criminal activity, employment, family harmony, and
the need for medical and social services. The benefit is generally
believed to outweigh the cost. Improvement is greatest while
treatment continues, with some decline (how much is disputed)
afterward. Patients who remain in treatment longer are more
successful, but what makes them stay is uncertain. Treatment is
least effective for those with the most serious problems. It has
rarely been shown clearly that one treatment is better than another,
either for addicts in general or for a particular class of addicts.
One major summary of outcome research is the Drug Abuse Research
Project Survey (DARPS), a 12-year follow-up of opiate addicts
admitted to methadone, residential, or outpatient drug-free
treatment beginning in 1969. Moderate improvement was found in all
three programs, but 83% of the patients had been treated more than
once by the end of the survey, and 74% had taken methadone at some
time. Another analysis is the Treatment Outcome Prospective Study
(TOPS), which collected data on 10,000 patients in 41 drug abuse
programs beginning in 1979, with a follow-up of three to five years.
Drug use declined with treatment, although the effect was
statistically significant only after six months. Crime decreased for
three to five years, but some illicit drug use usually continued. In
both the DARP and the TOPS surveys, any treatment was better than
being put on a waiting list, but differences among the treatments
were less significant. The dropout rate was about 60% for
therapeutic communities and outpatient drug-free programs, 35% for
methadone.
The findings of other studies are similar. Cocaine addicts
treated at a VA Medical Center in Philadelphia had a better outcome
than addicts placed on a waiting list at the same time. A 1992 study
of 350 Minnesota alcohol and drug programs, with a follow-up of six
months, found considerably higher rates of abstinence and employment
and lower rates of crime and drunk driving after treatment. A 1992
study sponsored by the state of California found that alcohol and
drug treatment programs were effective regardless of the nature of
the program and the race or social class of the patient. After
treatment, the crime rate among patients declined 66%, alcohol and
drug use 40%, and the hospitalization rate 33%. Treatments for
alcohol, heroin, and cocaine addiction were equally effective.
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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