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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 monthly for $60 per year by the Harvard Medical School Health Publications Group, 164 Longwood Ave., Boston, MA 02115. Second-class postage paid at Boston, MA, and additional mailing offices. Postmaster: Send address changes to The Harvard Mental Health Letter, P.O. Box 420448, Palm Coast, FL 32142-0448.

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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