Treating opiate addiction, Part II:
Alternatives to maintenance

(This article was first printed in the January 2005 issue of the Harvard Mental Health Letter. For more information or to order, please go to www.health.harvard.edu/mental.)

Naltrexone

A different kind of drug treatment for opiate addicts is the long-acting opiate antagonist naltrexone, taken three times a week after detoxification. It blocks opiate receptors, 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. An authoritative review of controlled studies concludes that at present there is not enough evidence to justify this use of naltrexone. But even if most addicts will not continue to take the drug, some may — especially physicians and other middle-class patients who are highly motivated to get free of the opiate because they have so much to lose from a persistent addiction.

Drug chemists are now trying to make it more difficult to discontinue naltrexone by providing it in the form of an injection under the skin for slow release over a period of several weeks. As of 2005, this product has not yet received FDA approval.

Behavioral treatment

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.

A special form of behavioral treatment is contingency management. Addicts are given vouchers they can redeem for goods and services if their urine remains free of drugs. Patients may also take naltrexone to make casual relapse more difficult. Although contingency management has been found effective in some studies, critics say that it costs too much and is too difficult to put into practice.

Psychotherapy

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 rather than treated as the symptom of some other emotional problem. 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 therapy

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.

Residential treatment

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 who lack jobs, stable marriages, and sometimes even homes.

Support groups

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.

Family counseling

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, preparation, contemplation, 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.

Resources

American Society of Addiction Medicine
301-656-3920
www.asam.org

Buprenorphine Information Center
866-287-2728 (toll free)
www.buprenorphine.samhsa.gov

Narcotics Anonymous World Services
818-773-9999
www.na.org

National Institute on Drug Abuse
301-443-1124
www.drugabuse.gov

Smart Recovery
866-951-5357 (toll free)
www.smartrecovery.org

Substance Abuse and Mental Health Services Administration (SAMHSA)
800-662-4357 (toll free)
http://findtreatment.samhsa.gov

(This article was first printed in the January 2005 issue of the Harvard Mental Health Letter. For more information or to order, please go to www.health.harvard.edu/mental.)

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