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Modern treatment of substance abuse
Drug and Alcohol Elsevier Scientific
Dependence, 11 (1983) Publishers Ireland Ltd.
95-97
95
MODERN TREATMENT OF SUBSTANCE ARUSE
CHARLES P. O’BRIEN, GEORGE Philadelphia (U.S.A.)
E. WOODY and A. THOMAS McLELLAN
VA Medical Center and the University
of Pennsylvania.
Philadelphia,
PA
Although the public generally regards all forms of addiction as uniformly ‘incurable,’ recent outcome studies have shown that treatment actually results in substantial improvement. In fact, the nature and degree of improvements seen among substance abuse patients are comparable to those seen in the treatment of many other disorders, both phychological and medical. Why then does this reputation for limited efficacy in drug abuse treatment persist even among professionals? It probably discourages many potentially good therapists from entering the field of substance abuse and it may create an aura of low status among health-care professionals. Perhaps one major reason is the acceptance of unrealistic treatment goals. Success for the drug abuse patient has often been defined as being drugfree, legally employed and not engaging in crime. These are laudable goals for any health care service, but for a drug treatment program to implicitly or explicitly adopt them as evaluation standards is to invite unreasonable and unfair judgment. For example, much of the criminal behavior seen among our patients actually preceded drug involvement. Similarly, employment is partly a function of skills and habits developed prior to drug involvement and partly a function of economic conditions. It is therefore not reasonable to expect that reductions in drug use will be immediately translated into more pervasive social improvements. Further, these expectations detract from the substantial and highly replicable improvements seen in drug use, psychological status and family relations following substance abuse treatments. These are important, direct measures of the treatment process and fair standards of efficacy. A second reason for the view that drug dependence treatments have limited efficacy is the failure to recognize the heterogeneity and complexity of problems found among drug abusing patients. While it is not understood among the general public, workers in the field are well aware that all drug abusers are not alike. However, even within the field there has been a failure to adequately assess the range and variability of treatment problems found within our patient populations. For example, several studies have now indicated that the full spectrum of psychiatric disorders is found in substance abuse patients, about 80% of whom meet 0376~8716/83/$03,00 0 1983 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
96
DSM III criteria for a diagnosis other than substance abuse. These modem diagnostic studies have contradicted earlier, simplistic assumptions that drug abusers were merely anti-social personalities. Detailed examinations of other problems commonly found among drug abusers reveals a similar range in complexity and severity. It has been our experience that these treatment problems combine in various ways to support substance abuse and to create particular treatment needs. Failure to adequately assess these treatment problems and to incorporate the information in a treatment plan results in the de facto position of treating all drug abusers alike. This raises a final reason for the traditional pessimism regarding treatment efficacy in substance abuse; the failure to recognize the conceptual and methodological differences among the various substance abuse treatments and to utilize these different treatments appropriately during the course of rehabilitation. The past decade has seen the development of multiple forms of treatment possibilities for substance abuse. Structurally, they may be divided into four types: maintenance (methadone or LAAM), detoxification, antagonist and drug-free. These four types of treatment offer very different approaches to addiction and may be most effectively utilized in sequential combinations at various points during rehabilitation. However, too often, proponents of one type of therapy have attempted to compete with other types of therapy, thereby ignoring the potential specific benefits of each type and reducing the overall level of efficacy by forcing an inappropriate approach. Our research findings and clinical experience indicate that many types of treatment.& may be combined effectively for subgroups of the patient populations. For example, an opiate dependent patient may begin on maintenance, progress after months or years to detoxification, then a period of several months on an antagonist (naltrexone) and then continue in drug free therapy. In combination with these different program structures, a variety of psychological therapies have been found to add to the overall effectiveness of drug abuse treatment by addressing the particular constellation of problems which are often associated with the drug involvement. Individual psychotherapy (either cognitive-behavioral or supportive-expressive) has been found under controlled conditions to be effective in methadone patients. A variety of behavior modification techniques, often in combination with naltrexone, have been reported to have benefits in extinguishing drug-conditioned responses which may lead to relapse. Family therapy in combination with methadone has been subjected to a carefully controlled study and has been found to be effective. Vocational counselling and legal counselling have been combined with methadone treatment with reported added benefits. Thus each of the treatment structures can be combined with an appropriate psychological treatment depending on the needs of the individual. Psychotropic medication adds yet another dimension to the treatment
91
possibilities. Anti-depressant medication in combination with methadone has been reported to be effective in several controlled studies. When disorders such as schizophrenia or affective disorders are diagnosed in substance abuse patients, neuroleptics or lithium may be combined with maintenance, drug-free or antagonist program structures. Even benssodiazepines, which themselves have a potential for abuse may be used in conjunction with naltrexone to reduce protracted abstinence symptoms and improve program retention. Opiate dependent patients for whom a rapid detoxification is desirable may benefit from a clonidine assisted detoxification prior to drug-free or antagonist therapy. While only a few clinics provide all possibilities now, the coming decade should see the full range available at most treatment centers. This is critical because recent work shows that the wrong treatment may provide no benefit or even worsen patient status, whereas the patient could be expected to respond if the appropriate therapy or complex of treatments is given. The modern approach to the treatment of substance abuse, therefore, involves an accurate diagnostic assessment of the type of disability in a variety of areas and then matching the patient to the appropriate treatment. It is incumbent on providers of care to develop flexible, multimodality programs. We now have evidence that multiple treatments are effective and in the long run they may be more economical than assigning patients to a single modality which benefits some but does not respond to the problems of others. SUGGESTED
READING
A.T. McLellan et al., J. Nerv. Ment. Dis., 168 (1980) 26. A.T. McLellan et al., J. Am. Med. Assoc., 247 (1982) 1423. C.P. O’Brien and R.A. Greenstein, Treatment approaches: Opiate antagonists, in: J.H. Lowinson and P. Ruiz (Eds.), Substance Abuse: Clinical Problems and Perspectives, Williams & Wilkins, Baltimore, 1981. B.J. Rounsaville et al., Arch. Gen. Psychiat., 39 (1982) 161. D.D. Simpson et al., Evaluation of Drug Abuse Treatments Based on First Year Follow-up, National Institute Drug Abuse services research monograph ADM 78701, U.S. Department of Health, Education and Welfare, Rockville, MD, 1978. G.E. Woody et al., Arch. Gen. Psychiat., (1983) in press.
Dependence, 11 (1983) Publishers Ireland Ltd.
95-97
95
MODERN TREATMENT OF SUBSTANCE ARUSE
CHARLES P. O’BRIEN, GEORGE Philadelphia (U.S.A.)
E. WOODY and A. THOMAS McLELLAN
VA Medical Center and the University
of Pennsylvania.
Philadelphia,
PA
Although the public generally regards all forms of addiction as uniformly ‘incurable,’ recent outcome studies have shown that treatment actually results in substantial improvement. In fact, the nature and degree of improvements seen among substance abuse patients are comparable to those seen in the treatment of many other disorders, both phychological and medical. Why then does this reputation for limited efficacy in drug abuse treatment persist even among professionals? It probably discourages many potentially good therapists from entering the field of substance abuse and it may create an aura of low status among health-care professionals. Perhaps one major reason is the acceptance of unrealistic treatment goals. Success for the drug abuse patient has often been defined as being drugfree, legally employed and not engaging in crime. These are laudable goals for any health care service, but for a drug treatment program to implicitly or explicitly adopt them as evaluation standards is to invite unreasonable and unfair judgment. For example, much of the criminal behavior seen among our patients actually preceded drug involvement. Similarly, employment is partly a function of skills and habits developed prior to drug involvement and partly a function of economic conditions. It is therefore not reasonable to expect that reductions in drug use will be immediately translated into more pervasive social improvements. Further, these expectations detract from the substantial and highly replicable improvements seen in drug use, psychological status and family relations following substance abuse treatments. These are important, direct measures of the treatment process and fair standards of efficacy. A second reason for the view that drug dependence treatments have limited efficacy is the failure to recognize the heterogeneity and complexity of problems found among drug abusing patients. While it is not understood among the general public, workers in the field are well aware that all drug abusers are not alike. However, even within the field there has been a failure to adequately assess the range and variability of treatment problems found within our patient populations. For example, several studies have now indicated that the full spectrum of psychiatric disorders is found in substance abuse patients, about 80% of whom meet 0376~8716/83/$03,00 0 1983 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
96
DSM III criteria for a diagnosis other than substance abuse. These modem diagnostic studies have contradicted earlier, simplistic assumptions that drug abusers were merely anti-social personalities. Detailed examinations of other problems commonly found among drug abusers reveals a similar range in complexity and severity. It has been our experience that these treatment problems combine in various ways to support substance abuse and to create particular treatment needs. Failure to adequately assess these treatment problems and to incorporate the information in a treatment plan results in the de facto position of treating all drug abusers alike. This raises a final reason for the traditional pessimism regarding treatment efficacy in substance abuse; the failure to recognize the conceptual and methodological differences among the various substance abuse treatments and to utilize these different treatments appropriately during the course of rehabilitation. The past decade has seen the development of multiple forms of treatment possibilities for substance abuse. Structurally, they may be divided into four types: maintenance (methadone or LAAM), detoxification, antagonist and drug-free. These four types of treatment offer very different approaches to addiction and may be most effectively utilized in sequential combinations at various points during rehabilitation. However, too often, proponents of one type of therapy have attempted to compete with other types of therapy, thereby ignoring the potential specific benefits of each type and reducing the overall level of efficacy by forcing an inappropriate approach. Our research findings and clinical experience indicate that many types of treatment.& may be combined effectively for subgroups of the patient populations. For example, an opiate dependent patient may begin on maintenance, progress after months or years to detoxification, then a period of several months on an antagonist (naltrexone) and then continue in drug free therapy. In combination with these different program structures, a variety of psychological therapies have been found to add to the overall effectiveness of drug abuse treatment by addressing the particular constellation of problems which are often associated with the drug involvement. Individual psychotherapy (either cognitive-behavioral or supportive-expressive) has been found under controlled conditions to be effective in methadone patients. A variety of behavior modification techniques, often in combination with naltrexone, have been reported to have benefits in extinguishing drug-conditioned responses which may lead to relapse. Family therapy in combination with methadone has been subjected to a carefully controlled study and has been found to be effective. Vocational counselling and legal counselling have been combined with methadone treatment with reported added benefits. Thus each of the treatment structures can be combined with an appropriate psychological treatment depending on the needs of the individual. Psychotropic medication adds yet another dimension to the treatment
91
possibilities. Anti-depressant medication in combination with methadone has been reported to be effective in several controlled studies. When disorders such as schizophrenia or affective disorders are diagnosed in substance abuse patients, neuroleptics or lithium may be combined with maintenance, drug-free or antagonist program structures. Even benssodiazepines, which themselves have a potential for abuse may be used in conjunction with naltrexone to reduce protracted abstinence symptoms and improve program retention. Opiate dependent patients for whom a rapid detoxification is desirable may benefit from a clonidine assisted detoxification prior to drug-free or antagonist therapy. While only a few clinics provide all possibilities now, the coming decade should see the full range available at most treatment centers. This is critical because recent work shows that the wrong treatment may provide no benefit or even worsen patient status, whereas the patient could be expected to respond if the appropriate therapy or complex of treatments is given. The modern approach to the treatment of substance abuse, therefore, involves an accurate diagnostic assessment of the type of disability in a variety of areas and then matching the patient to the appropriate treatment. It is incumbent on providers of care to develop flexible, multimodality programs. We now have evidence that multiple treatments are effective and in the long run they may be more economical than assigning patients to a single modality which benefits some but does not respond to the problems of others. SUGGESTED
READING
A.T. McLellan et al., J. Nerv. Ment. Dis., 168 (1980) 26. A.T. McLellan et al., J. Am. Med. Assoc., 247 (1982) 1423. C.P. O’Brien and R.A. Greenstein, Treatment approaches: Opiate antagonists, in: J.H. Lowinson and P. Ruiz (Eds.), Substance Abuse: Clinical Problems and Perspectives, Williams & Wilkins, Baltimore, 1981. B.J. Rounsaville et al., Arch. Gen. Psychiat., 39 (1982) 161. D.D. Simpson et al., Evaluation of Drug Abuse Treatments Based on First Year Follow-up, National Institute Drug Abuse services research monograph ADM 78701, U.S. Department of Health, Education and Welfare, Rockville, MD, 1978. G.E. Woody et al., Arch. Gen. Psychiat., (1983) in press.