Treating opiate addiction, Part
II: Alternatives to maintenance
(Continued from Part I)
A different kind of drug treatment for opiate addicts is
the long-acting opiate antagonist naltrexone, taken three times a week
after detoxification. It neutralizes or reverses the effects of opiates,
and triggers a withdrawal reaction in anyone who is physically dependent
on opiates. An addict who takes naltrexone faithfully will never relapse,
but most addicts simply stop using it, or refuse to take it in the
first place. But even if most addicts will not continue to take the
drug, some may — especially patients who are highly motivated
to get free of the opiate because they have so much to lose from a
persistent addiction. An injectable, slow-release version of naltrexone
is under development, but this product is not yet available and has
not received FDA approval.
Behavioral therapists regard opiate addiction as the effect
of learned associations and patterns of reward and punishment. Patients
learn to identify and remember moods, thoughts, and situations that
tempt them to use opiates. The therapist helps them avoid these temptations,
consider the consequences of relapse, and find other ways to achieve
a feeling of pleasure or accomplishment. Training in stress management,
relaxation, and general problem-solving may also help. Cognitive therapists
try to help addicts recognize and dismiss self-defeating attitudes
that make life seem unbearable without the drug.
Individual psychotherapy is never recommended as the main
treatment for opiate addiction; it rarely succeeds because addicts
are reluctant participants at best. Addiction must be addressed directly.
But opiate addicts often have psychiatric symptoms and psychiatric
disorders, and some of these dually diagnosed patients can make good
use of psychotherapy — psychodynamic, interpersonal, or supportive — as
long as the addiction is treated at the same time.
Group treatment is often preferred for addicts. It makes
use of the need to belong and the healing power of human connections.
The group helps addicts feel less isolated and ashamed and allows them
to help themselves by helping others. Groups can provide both emotional
support and confrontation, along with information and understanding.
Some withdrawing addicts are treated in residential chemical
dependency programs that provide individual and group therapy, 12-step
support groups, and other services, usually for a month to three months.
Other addicts join therapeutic communities, in which they are expected
to remain for six months to two years, participating in group meetings
while following strict rules that allow them gradually to acquire more
personal freedom as they show their capacity to assume responsibility
and avoid drugs. Middle-class addicts are more likely to enroll in
chemical dependency programs; residential therapeutic communities usually
attract street heroin addicts with fewer resources.
Mutual aid groups for opiate addicts follow the same lines
as those established earlier for alcoholics. The best known, Narcotics
Anonymous, uses the 12-step procedures developed by Alcoholics Anonymous.
Other self-help groups, such as Smart Recovery, rely less on appeals
to a higher power and more on cognitive and behavioral principles.
Where possible, it is important to enlist the addict’s
family. Relatives can be coached on how to confront the patient or
taught how to facilitate cognitive and behavioral therapy. In a variant
called network therapy, friends and relatives become part of the therapeutic
team, meeting to discuss what to do in relapses and other emergencies.
Relatives can also join family support groups like Narc-Anon.
Stages of change
In any kind of treatment for addiction, it is important to
understand what kind of change is possible at a given time for a given
person. Researchers have discovered five stages through which most
people go when they decide to change their lives: precontemplation,
contemplation, preparation, action, and maintenance.
At the precontemplation stage, they are not yet persuaded that they
have a problem; in addicts, this stage has previously been called denial.
At the contemplation stage, they have begun to acknowledge the need for
change but have not yet made a commitment. The preparation stage involves
plans for action, and maintenance means avoiding relapse.
Addicts rarely pass through these stages smoothly the first time. When
they stall or regress, they must be urged not to become demoralized and
give up. Some professionals who work with addicts believe that the choice
of treatment should depend on which stage they have reached; for example,
psychotherapy may help at the precontemplation and contemplation stages,
while cognitive and behavioral therapies may be more appropriate for
the action and maintenance stages.
State of the art and practice
Methadone maintenance remains the most successful treatment
for opiate addiction. Other approaches have a mixed record. But even
if no two addicts respond to the same approach, treatment does work
for many, and others eventually get free of the drug on their own.
But anger and resentment alternate with sympathy and concern in public
and professional attitudes toward opiate addiction. Physicians often
regard addicts as a nuisance and are reluctant to treat them. The public
has doubts about devoting medical resources to people who seem to have
brought their troubles on themselves and who may seem both demanding
and ungrateful when they are offered help. Opiate maintenance is still
politically and socially, although not medically, controversial; some
still regard it as official indulgence of a criminal vice. Methadone
clinics are strictly regulated, sometimes to the extent of setting the
maximum dose and length of treatment. Even so, the clinics are unpopular
with neighbors and waiting lists are long. Buprenorphine maintenance
is an exciting new development because it lacks some of these drawbacks
of methadone. For further improvement, we will need not only more effective
medications and therapeutic techniques, but also a better public understanding
of the disorder of opiate addiction.
May 2005 Update
Back to Previous Page