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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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