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Drug therapies

As is true in so many other areas of health care, drug therapies are very
popular these days in the addictions field
As we have learned, the disease models place great emphasis on the role of withdrawal in addiction; thus, they provide aggressive treatment for withdrawal - this aspect of treatment is known as 'detox' (for detoxification). Detox is usually done on an in-patient basis, and lasts for as long as the withdrawal lasts (treatment that continues beyond withdrawal is usually referred to as 'Rehab'). The primary goals of detox are to ensure the patient's safety and to ease the patient's suffering. Drugs are a major part of this: • Minor tranquilizers, like Librium, wil be used to diminish the agitation and nervousness that addicts often feel during withdrawal • Major tranquilizers, like Stelazine and Haldol, wil be used for more powerful sedation and because these drugs also function as anti-psychotics, which means they can help to control hallucinations and delusions that often accompany In recent years, as disease models have placed great emphasis on biomedical research, there has been a dramatic, but also controversial, increase in interest in psychopharmacology - the use of medications designed to produce psychological Drugs can be used to treat addiction in three ways: 1. As antagonists - these drugs block the "high" or reduce the "craving" (for example, naltrexone with alcohol and opiates) 2. As agonists - these drugs work as substitutes by producing a similar, though less potent, effect (for example, methadone with opiates, nicotine patches or gum 3. As aversives - these drugs interact with the addictive drug to produce a very unpleasant reaction (for example, disulfiram, or Antabuse, with alcohol) Control ed clinical studies usually show that these drug approaches work better than placebo over the short term, but their efficacy over the long term is much less clear. For obvious reasons, the use of drugs to treat drug problems strikes many people as peculiar. Remember our history: heroin was introduced by a pharmaceutical company as a treatment for opium addiction. Methadone in particular has been very controversial. The last area in which drugs are often emphasized involves the possible overlap between addiction and some other psychiatric il ness. As we learned when we covered Person-Centered Theories of Addiction, there is a lot of evidence that addicts also frequently suffer from depression and anxiety (though distinguishing cause and effect can be tricky!). Thus, many physicians believe that one should treat the addiction by treating the anxiety or mood disorder, for which anti-depressant drugs like Paxil and Prozac and Zoloft have become increasingly popular. In recent years, there has also been interest in the possible link between Attention Deficit/Hyperactivity Disorder (ADHD) and substance abuse, and an increasing number of adult addicts with diagnoses of ADHD are being treated with stimulant drugs like Traditional psychotherapy and counseling approaches are often
suspect, but cognitive-behavioral methods are strongly supported by a
lot of good outcome research
Al the many different methods of treatment that focus on the mind and behavior rather than on the body are col ectively known as psychosocial interventions, and these are the Psychodynamic theories have traditionally viewed addiction as essentially a symptom of underlying mental forces, especially unconscious conflicts. In other words, the addict's addiction stems from some inner force ("neurosis" to use an out-dated term), and the goal of treatment has been insight rather than directly confronting the addiction itself. There is general agreement that these insight approaches are ineffective; figuring out why someone drinks seems to be less important than focusing directly on the problem drinking itself. Thus, modern psychodynamic approaches have adopted a three-stage model where the first stage emphasizes external controls to facilitate abstinence, and where the therapist's only real job is to promote abstinence. The second stage is designed to foster internalized controls by using the therapeutic relationship to provide support; in this stage, the client's "preferred defense structure" is preserved because the client is viewed as stil fragile. Only in the third stage, which many clients never reach, does the therapy begin to confront the defensive structure to promote fundamental personality change (which, if achieved, is then believed by many therapists to make it possible for the client to drink safely). There are also many other forms of psychotherapy and counseling that do not involve traditional Freudian psychodynamic methods or concepts. Inspired by the work of people like Carl Rogers and Abraham Maslow, these more "humanistic" or "client- centered" forms of counseling place major emphasis on the relationship itself as a vehicle for enabling clients to grow, or "self-actualize." With few empirical studies of these many different counseling methods, it is difficult to say whether they are effective. However, many professionals in the addictions field mistrust such methods, viewing them as "feel good" therapies that distract addicts from facing the fundamental fact of their addiction. Moreover, there is always the danger of "psychobabble," as so-called experts come up with all sorts of theories as to why people become addicted. Cognitive and Behavioral Models Behavioral models, which emphasize the role of learning in addiction, also emphasize the role of learning to modify addictive behavior. Behaviorists have tested a number of specific techniques: • Behavior (contingency) contracting • Community reinforcement • Aversion therapy • Behavioral marital therapy • Token economies Cognitive approaches zero in on the dysfunctional cognitions assumed to be responsible for addiction. Cognitive Therapy and Rational-Emotive Psychotherapy are two specific examples, along with the combined cognitive-behavioral approach in Relapse Prevention. Unlike more traditional forms of therapy and counseling, which rely heavily on subjective case studies, cognitive and behavioral approaches in addictions treatment are strongly supported by many rigorous experiments. Unfortunately, despite the strong supporting evidence, cognitive and behavioral methods have not been embraced by the addictions community. As we learned a few weeks ago, cognitive and behavioral psychologists have little use for any disease model and are not always committed to abstinence as a goal. We have already seen how much controversy was sparked by the Sobel s' study of control ed drinking. Since the addictions field in the United States is heavily dominated by the disease models, even the wel supported cognitive and behavioral methods are often not viewed very positively. In sheer numbers, the 12-step approaches are probably the most
important (but the least well understood)
In the 1930s, two men who had struggled for years to overcome their alcoholism began to gather together with other alcoholics seeking recovery, and from these early experiences, Alcoholics Anonymous (AA) was born. AA has come to be referred to as a "twelve step" program because it is built around a program of recovery divided into 12 steps. Alcoholics begin with the first step, which is their admission that they are "powerless over alcohol," and that their "lives had become [It is this powerlessness, as we have discussed before, that is central to AA's conception From its inception, AA was clearly designed as a quasi-religious organization. The second step to recovery asks alcoholics to admit that "a Power greater than ourselves (can) restore us to sanity," and in the third step, alcoholics make the "decision to turn our wil and our lives over to the care of God as we understood him." They then proceed, again and again, through the other steps, which ask them to engage in a "searching and fearless moral inventory," to admit "the exact nature of our wrongs," and to "make amends" to those whom they have harmed. And to keep the organization alive, the last step commits the alcoholic to "carry this message to (other) alcoholics." AA and the other Twelve Step organizations operate through individual local groups that, other than being officially recognized by AA's Central Committee, are completely autonomous and self-supporting (usually by passing the hat), holding scheduled meetings run by members and open to all who have "a desire to stop drinking (or whatever the addictive behavior might be)." The growth of AA has been astonishing: from 100 members in 1939 to 8,000 in 1941 to 200,000 by 1957 to over one and a half mil ion members in 1985, and now approaching three mil ion, affiliated with 40,000 different AA groups in over 100 countries. Also astounding is the fact that even though AA has never sought anyone's endorsement, it is now the most widely recommended form of addictions treatment in the U.S. - physicians, clergy, social workers, teachers, judges, employers, family members, all routinely recommend, and in some cases even require, that their patients/clients/students/defendants/employees/loved ones attend AA. And it is AA that has been chiefly responsible for the widespread acceptance of disease models of addiction, an interesting example of how a lay organization has been able to exert so much influence over healthcare professionals and scientists! AA also publishes numerous books and pamphlets, and it has been estimated that more people have obtained information about alcoholism from some form of AA literature than from all other sources combined. This perhaps partially explains why the disease models, so strongly embraced and promoted by AA, are so widely accepted. If you are interested, click here for AA's website: Over the years, as the concept of addiction has expanded, AA has led to many "spin- offs," with Narcotics Anonymous, Gamblers Anonymous, Overeaters Anonymous, Sex and Love Addicts Anonymous, Codependents Anonymous, etc. Because of their anonymous nature, and because as organizations they are committed to steering clear of involvement in other causes or with other groups or institutions, Twelve Step groups have not been very accessible to scientists for study. Moreover, because the groups themselves operate on the basis of what might be called "revealed truth," they have not felt the need to 'prove' what they already 'know' to be true. Thus, it is extremely difficult to obtain hard data as to whether these Twelve Step approaches work, or how they compare to other forms of treatment, or whether they work better for some types of people or addictions than others. Furthermore, to the extent that they do perhaps work, it is virtually impossible to know why: is it because one submits to a higher power, or because one admits to having a disease, or because one gets a lot of support from other alcoholics, or because one learns new ways of coping with life's problems? We just don't know. Because the Twelve Step approaches are closely al ied with the disease models of addiction, they are subject to many of the same criticisms that we covered early in the semester. Peele, as you can probably guess, has no use for the Twelve Step groups at all! At the same time, hundreds of thousands of people wil tel you with absolute conviction that AA (or NA or GA or whatever) "saved my life." Regardless of the specific form of treatment used, there are some
general treatment issues we need to be aware of
Cutting across all treatment approaches is the central problem of client motivation, which each perspective sees in different terms. For disease model advocates, the goal is to help clients to see that they are sick - motivation rests within the client. However, a central symptom of the disease is assumed to be denial, which interferes with addicts' ability to recognize that they are Psychodynamic therapists emphasize the unconscious defensive process associated with denial, rationalization and minimization - motivation stil rests within the client. With their emphasis on reinforcement, behaviorists make the issue of incentives a central feature - motivation is influenced by the environment. Cognitive therapists see motivation as a reflection of clients' expectancies and coping self-efficacy, which in turn reflect the on-going interaction between the person and his Family therapists see the family as a way to strengthen motivation, while those who draw on a socio-cultural perspective connect motivation to a client's values and goals and to the incentives and disincentives that society creates for being addicted and for Many therapists in recent years have adopted the stages of change view: • Pre-contemplation • Contemplation • Preparation/Determination • Action • Maintenance • Permanent Exit or Relapse The Contemplation stage is viewed as especially important in addictions treatment, an extended period where the client moves back and forth between admitting and denying a problem and between valuing and devaluing the possibility of change.
The challenge of client motivation has led to a lot of emphasis on coercion, where an
aversive stimulus is used to modify the addiction, by either (1) imposing the aversive stimulus, then taking it away, or (2) threatening it, then removing the threat. Coercion is evident in the increase in court-ordered treatment, treatment mandated by an employer, families' use of "tough love," and treatment requirements imposed as conditions of probation or parole or under Federal rules that govern transportation Does coercion work? Unfortunately, there are few empirical studies. If it helps, it might An alternative to coercion is confrontation, which is designed to forceful y challenge and overcome a client's denial; since denial is heavily emphasized within the disease models, those treatments are usually confrontational. However, in recent years, some have reconceptualized denial as an understandable interpersonal strategy, and have argued that confrontation actually increases denial. Techniques of motivation enhancement or motivational interviewing are now taking on increasing importance in the training of substance abuse professionals. One other approach, quite common in other countries but stil rare in the U.S., is known as harm-reduction, where the focus is less on the addictive behavior itself and more on trying to reduce the amount of harm done. Two current examples are (1) focusing less on the alcoholic's drinking and more on the pattern of drinking and driving, and (2) Managed care is also having an impact, with its emphasis on rationally matching levels and types of treatment with client needs, but so far there is little evidence that matching Peele's Critique of Contemporary Addictions Treatment in America In his analysis of treatment goals, Peele points out that problem drinkers differ in whether they perceive themselves as alcoholic and whether they perceive abstinence to Those who do perceive themselves as alcoholic and believe in abstinence might not respond wel to control ed drinking therapies, but those who don't see themselves as alcoholic often tend to shun treatment altogether. Peele further believes that these people often succeed on their own, pointing to Vail ant's own data that showed that only a small percentage of alcoholics in remission used AA and that many who had successful y cut down or stopped did so without any In Chapter 6, Peele finds fault with medical approaches to addiction treatment, which put so much emphasis on easing people through withdrawal, which Peele believes plays Furthermore, there is the danger that easing withdrawal reduces negative consequences Peele further argues that the emphasis on withdrawal and relapse and disease weakens self-efficacy; evidence shows that positive self-efficacy at the start of treatment is the He also points to the studies that typically show a negative correlation between the amount of treatment received and good outcomes (though it is important to remember that correlation doesn't prove causation, and this finding can be interpreted in different Peele is sharply critical of the "Alcoholism/Chemical Dependence Treatment Industry," which he holds responsible for the incredible growth in the number of supposed addicts and which has led to dramatic increases in the number of treaters and industry's revenues, especial y with its reliance on expensive in-patient treatment. The rapid rise in the number of addicts has come about by identifying whole new populations of people seen as needing addictions treatment (alcohol abusers, teenage drinkers, workers drinking on the job, ACOAs, co-dependents, DUI offenders). Furthermore, Peele believes that the addictions industry only pays lip service to prevention; the bulk of Federal money goes into biomedical research and The addictions industry further benefits from all the newly-"discovered" addictions, for which specialized treatment centers have been opening up, often owned by large for- Peele believes that the "cure" for addiction occurs when realistic action and real rewards replace the addictive object and artificial rewards. Though Peele does not believe that professional treatment is essential, he sees it as potentially valuable. Treatment should be designed to help addicts (a) realize that their addiction is hurting them, (b) develop enough self-efficacy to cope with withdrawal and deprivation, and (c) find alternative and more genuine life rewards.


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(1) Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ 2010; 88(7):509-518. Special Programme for Research and Training in Tropical Diseases, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland. . (2) Atkinson JA, Vallely A, Fitzgerald L, Whittaker M, Tanner M. The architecture

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