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Treating opiate addiction, Part II: Alternatives to maintenance
The is the second part of "Treating opiate addiction". Click here to read Part I: Detoxification and maintenance.
A different kind of drug treatment for opioid use disorder is the long-acting opiate antagonist naltrexone, usually taken once per day after detoxification. It neutralizes or reverses the effects of opiates, and triggers a withdrawal reaction in anyone who is physically dependent on opiates. A person who takes naltrexone faithfully will never relapse, but most people simply stop using it, or refuse to take it in the first place. A newer slow-release naltrexone injection is now available. However, it is too soon to know if it will have a better success rate than the oral form.
Behavioral therapists regard opioid use disorder 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 patients recognize and dismiss self-defeating attitudes that make life seem unbearable without the drug.
Individual psychotherapy is not recommended as the main treatment for opiate addiction; it rarely succeeds because people with opioid use disorder are reluctant participants at best. Addiction must be addressed directly. But people with any substance abuse disorder 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 people with opioid use disorder. It makes use of the need to belong and the healing power of human connections. The group helps patients 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.
For some people treatment in a residential chemical dependency program can be helpful. These types of programs may provide individual and group therapy, 12-step support groups, and other services, usually for a month to three months. Other people with opioid use disorder may 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.
Mutual aid groups for people with opioid use disorder 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 patient'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: pre-contemplation, contemplation, preparation, action, and maintenance.
At the pre-contemplation stage, they are not yet persuaded that they have a problem; 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.
People with opioid use disorder 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 these patients believe that the choice of treatment should depend on which stage they have reached; for example, psychotherapy may help at the pre-contemplation and contemplation stages, while cognitive and behavioral therapies may be more appropriate for the action and maintenance stages.
State of the art and practice
Suboxone and methadone maintenance are the most successful treatment for opioid use disorder. Other approaches have a mixed record. But even if no two patients respond to the same approach, treatment does work for many, and others eventually get free of the drug on their own.
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