|Written by Charles P O'Brien|
|Sunday, 17 December 2000 00:00|
Myths about the treatment of addiction
Charles P O'Brien, A Thomas McLellan
Although addictions are chronic disorders, there is a tendency for most physicians and for the general public to perceive them as being acute conditions such as a broken leg or pneumococcal pneumonia. In this context the acute-care procedure of detoxification has been thought of as appropriate "treatment". When the patient relapses, as most do sooner or later, the treatment is regarded as a failure. However, contrary to commonly held beliefs, addiction does not end when the drug is removed from the body (detoxification) or when the acute post drug= taking illness dissipates (withdrawal). Rather, the underlying addictive disorder persists, and this persistence produces a tendency to relapse to active drug-taking. Thus, although detoxification as explained by Mattick and Hall (Jan 13, p 97)' can be successful in cleansing the person of drugs and withdrawal symptoms, detoxification does not address the underlying disorder, and thus is not adequate treatment.
As we shall discuss, addictions are similar to other chronic disorders such as arthritis, hypertension, asthma, and diabetes. Addicting drugs produce changes in brain pathways that endure long after the person stops taking them. Further, the associated medical, social, and occupational difficulties that usually develop during the course of addiction do not disappear when the patient is detoxified. These protracted brain changes and the associated personal and social difficulties put the former addict at great risk of relapse. Treatments for addiction, therefore, should be regarded as being long terra, and a "cure" is unlikely from a single course of treatment.
Is addiction a voluntary disorder?
Comparison to other medical disorders
Successful treatment leads to substantial improvement in three areas: reduction of alcohol and other drug use; increases in personal health and social functions; and reduction in threats to public health and safety. All these domains can be measured in a graded fashion with a method such as the Addiction Severity Index (ASI) 7 In the ASI, a structured interview determines the need for treatment in seven independent domains. These measurements allow us to see addiction, not as an all-or none disease, but in degrees of severity across all the areas relevant to successful treatment.
Success rates for treatment of addictive disorders vary according to the type of drug and the variables inherent in the population being treated, For example, prognosis is much better in opioid addicts who are professionals, such as physicians or nurses, than in individuals with poor education and no legitimate job prospects, who are addicted to the same or even lesser amounts of opioids obtained on the street and financed by crime. Figure 1 compares the ASI profiles of two patients admitted to our treatment programme. One was a resident physician who had few personal or professional difficulties except for heavy compulsive cocaine use. The other patient was a pregnant teenager, who was admitted while in premature labour induced by cocaine. The profile shows less drug use in the young woman, but in other areas shown to be important determinants of the outcome of treatment she has severe problems. The types of treatment needed by these two patients are clearly. different. Although the treatment of the physician will be challenging, his prognosis is far better than that of the young woman.
Success rates for the treatment of various addictive disorders are shown in table 1. Improvement is defined as a greater than 50% reduction on the drug-taking scale of the ASI. Another measure of the success of addiction treatment is the monetary savings that it produces. That addiction treatment is cost-effective has been shown in many studies in North America. For example, in one study in California, the benefits of alcohol and other drug treatment outweighed the cost of treatment by four to 12fold depending on the type of drug and the type of treatment.
There has been progress in the development of medications for the treatment of nicotine, opioid, and alcohol addictions. For heroin addicts, maintenance treatment with a long-acting opioid such as methadone, 1-a-acetylmethadol (LRAM), or buprenorphine can also be regarded as a success. The patient may be abstinent from illegal drugs and capable of functioning normally in society while requiring daily doses of an orally administered opioid medication-in very much the same way that diabetic patients are maintained by injections of insulin and hypertensive patients are maintained on betablockers to sustain symptom improvements. Contrary to popular belief, patients properly maintained on methadone do not seem "drugged". They can function well, even in occupations requiring quick reflexes and motor skills, such as driving a subway train or motor vehicle. Of course not all patients on methadone can achieve high levels of function. Many street heroin addicts, such as the young cocaine-dependent woman in figure 1, have multiple additional psychosocial difficulties, are poorly educated, and misuse many drugs. In such cases, intensive psychosocial supports are necessary in addition to methadone; even then, the prognosis is limited by the patient's ability to learn skills for legitimate employment..
Nicotine is the addicting drug that has the poorest success rate (table 1). That these success rates are for individuals who came to a specialised clinic for the treatment of their addiction, implies that the patients tried to stop or control drug use on their own but have been unable to do so. Of those who present for treatment for nicotine dependence, only about 20-30% have not resumed smoking by the end of 12 months.
Patient compliance is also especially important in determining the effectiveness of medications in the treatment of substance dependence. Although the general area of pharmacotherapy for drug addiction is still developing, in opioid and alcohol dependence there are several well-tested medications that are potent and effective in completely eliminating the target problems of substance use. Disulfiram has proven efficacy in preventing the resumption of alcohol use among detoxified patients. Alcoholics resist taking disulfiram because they become ill if they take a drink while receiving this medication; thus compliance is very poor.20
Naltrexone is an opioid antagonist that prevents relapse to opioid use by blocking opioid receptors; it is a nonaddicting medication that makes it impossible to return to opioid use, but it has little acceptance among heroin addicts who simply do not comply with this treatment. Naltrexone is also helpful in the treatment of alcoholism. Animal and human studies have shown that the reward produced by alcohol involves the endogenous opioid system. After patients are detoxified from alcohol, naltrexone reduces craving and blocks some of the rewarding effects of alcohol if the patient begins to drink again. 2 2,23 Naltrexone also decreases relapse rates (figure 2)." Although compliance is substantially better for naltrexone in the treatment of alcoholism than in opioid addiction, efforts to improve compliance are pivotal in the treatment of alcoholism. Continuing clinical research in this area is focused on the development of longer-acting forms of these medications and behavioural strategies to increase patient compliance.
The diseases of hypertension, diabetes, and asthma are also chronic disorders that require continuing care for most, if not all, of a patient's life. At the same time, these disorders are not necessarily unremitting or unalterably lethal, provided that the treatment regimen of medication, diet, and behavioural change is followed. This last point requires emphasis. As with the treatment of addiction, treatments for these chronic medical disorders heavily depend on behavioural change and medication compliance to achieve their potential effectiveness. In a review of over 70 outcome studies of treatments for these disorders (summarised in table 2) patient compliance with the recommended medical regimen was regarded as the most significant determinant of treatment outcome. Less than 50% of patients with insulin-dependent diabetes fully comply with their medication schedule,24and less than 30% of patients with hypertension or asthma comply with their medication regimens.25 ,26 The difficulty is even worse for the behavioural and diet changes that are so important for the maintenance of short-term gains in these conditions. Less than 30% of patients in treatment for diabetes and hypertension comply with the recommended diet and/or behavioural changes that are designed to reduce risk factors for reoccurrence of these disorden. 27 ,28 It is interesting in this context that clinical researchers have identified low socioeconomic status, comorbid psychiatric conditions, and lack of family support as the major contributors to poor patient compliance in these disorders (see ref 27 for discussion of this work). As in addiction treatment, lack of patient compliance with the treatment regimen is a major contributor to reoccurrence and to the development of more serious and more expensive "disease-related" conditions. For example, outcome studies show that 30-60% of insulin-dependent diabetic patients, and about 50-80% of hypertensive and asthmatic patients have a reoccurrence of their symptoms each year and require at least restabilisation of their medication and/or additional medical interventions to re-establish symptom remission.24-26 Many of these reoccurrences also result in more serious additional health complications. For example, limb amputations and blindness are all too common consequences of treatment non-response among diabetic patients.29,30 Stroke and cardiac disease are often associated with exacerbation of hypertension.31, 32
There are, of course, differences in susceptibilty, onset, course, and treatment response among all the disorders discussed here, but at the same time, there are clear parallels among them. All are multiply determined, and no single gene, personality variable, or environmental factor can fully account for the onset of any of these disorders. Behavioural choices seem to be implicated in the initiation of each of them, and behavioural control continues to be a factor in determining their course and severity. There are no "cures" for any of them, yet there have been major advances in the development of effective medications and behavioural change regimens to reduce or eliminate primary symptoms. Because these conditions are chronic, it is acknowledged (at least in the treatment of diabetes, hypertension, and asthma) that maintenance treatments will be needed to ensure that symptom remission continues. Unfortunately, other common features are their resistance to maintenance forms of treatment (both medication and behaviour aspects) and their chronic, relapsing course. In this regard, it is striking that many of the patient characteristics associated with non-compliance are identical for these acknowledged "medical" disorders and addictive disorders; and the rates of reoccurrence are also similar.
Addiction treatment is a worthwhile medical endeavour
Supported by VA Medical Research Service and NIH/NIDA grant no P50-DA-05186. We thank Dr Debrin Goubert for her assistance with the review of medical literature.
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