Treating opiate addiction, Part II: Alternatives to maintenance

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 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.

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 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 with fewer resources.

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, 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.

(This article was first printed in the January 2005 issue of the Harvard Mental Health Letter.)

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