Journal of the

Royal Society of Medicine Volume 85 August 1992 469

Substance Abuse

Addiction: treatment and outcome M Gossop PHD FBPsS Drug Dependence Clinical Research and Treatment Unit, The Bethlem Royal Hospital and The Maudsley Hospital, Beckenham BR3 3BX Keywords: addiction; heroin; treatment; outcome; relapse

Traditional views of drug addiction have been pessimistic about outcome, suggesting that people who become dependent upon drugs seldom give up and that treatment has little effect. An editorial in the first edition of the International Journal of the Addictions stated that there is no relationship between treatment and outcome, and that 'the great majority of addicts simply resume drug use". Similarly, a review of treatment evaluation studies noted that 'the treatment of heroin addiction has been singularly unsuccessful'2. There are, however, two important but separate issues here. The first is whether or not people who are addicted to drugs can successfully give up, and the second is what role is played by treatment in the process of giving up.

Giving up drugs On the first question that of whether addicts can give up drugs, there is increasing evidence that this occurs more frequently than was once believed. The traditional view has tended to see addiction in terms of progressive deterioration, and natural history formulations have often been more concerned to account for the deterioration of the addict than to allow for the possibilities of recovery. In its crudest form, this view can be found in the 'dope fiend' myth of inevitable social, moral and physical decline that is assumed to accompany confirmed drug use. However, many addicts do give up taking drugs. In a review of longitudinal studies, Thorley3 concluded that there is a gradual and steady trend towards abstinence, and a 10-year follow-up study of a group of heroin addicts who approached London drug clinics in 1969 estimated that 38% of this sample had become abstinent4. There was considerable evidence for the stability of abstinence. Of the 40 people who had maintained abstinence for 9 months or more at the 7 year follow-up, only two relapsed to heroin use by -

the 10th

year.

Among the studies that are sometimes cited as having had a powerful influence upon current understanding about the course of drug addiction are those that were carried out among the American troops serving in Vietnam during the war. Robins and her colleagues conducted comprehensive epidemiological surveys of the drug taking habits of US servicemen who served in Vietnam during 1971 when heroin use was especially widespread.

Robins5 estimated that 44% of the troops had used Paper read to opiates and 20% of the men had been addicted. joint meeting of However, most Vietnam drug takers did not carry Sections of their patterns of substance abuse back to America. Epidemiology & After discharge from the army, only a small minority Public Health became readdicted; 7% reported having used opiates, and Psychiatry and 1% felt they had been addicted. Even among 13 February 1991 those who had been addicted to opiates in Vietnam fewer than 10% continued to use opiates after their return.

Selfchange There is a growing interest in processes of selfchange among drug abusers - that is, with changes in drug taking patterns, including cessation, that occur without any formal treatment. In the case of cigarette smokers, for example, the majority of -people give up smoking without any sort of formal treatment intervention6. Similarly, many people with alcohol problems also give up without treatment7. Biernacki8 investigated a group of heroin addicts who had deliberately chosen not to become involved in treatment as a way of giving up. The majority believed either that there was no need for formal treatment because they could take care of themselves or they thought that treatment would not help. For Biernacki's subjects, breaking away from addiction was often accomplished by moving away (geographically) from the location in which the drug taking patterns had been established. In other cases, the moving away was achieved by the person putting a 'social distance' between themselves and their previous drug using friends and environments. A study of self-detoxification by heroin addicts9, found that almost all had previously made at least one self-detoxification attempt. Most had made repeated self-detoxification attempts without treatment assistance. However, although many of the subjects reported having managed to complete at least one such detoxification attempt and become drug-free, the success rate per episode was low with only 14% of the attempts leading to abstinence from opiates. Various different self-detoxification approaches were employed but one of the most commonly reported methods involved an abrupt cessation of opiates ('cold turkey'). Benzodiazepines were also commonly used to help alleviate withdrawal symptoms and these drug were felt to; be quite effective in this role. The addicts in this study also reported using a number of non-pharmacological strategies to help them cope with withdrawal problems. The most common were practical coping responses such as distraction and avoidance. Because self-detoxification attempts are common among drug addicts and because these attempts have a relatively low probability of success, self-help detoxification materials for opiate addicts could play a- useful role in supporting these efforts. Such materials have already been used with problem drinkers and cigarette smokers.

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The role of treatment The role played by treatment in helping addicts to give up drugs is complex, and the evidence about the effectiveness of specific treatments is often difficult to interpret clearly. In order to understand the effectiveness of treatment it is necessary first to ask the right questions. For example, an editorial in the British Journal of Hospital Medicine has warned against asking questions of the type 'what is the most effective way totreat opiate addiction?'10. The problemsof drug abuse cannot be fitted within a single unitary category. Instead they are a diverse range of different clusters of problems. It makes no more sense to ask what is the most effective treatment for drug abuse than it does to ask what is the most effective treatment for mental illness. It is necessary to create more precise definitions ofthe problem with a clearer specification ofthe sub-groups and underlying dimensions. In the absence of any clear understanding of the underlying dimensions, treatments for drug dependence should be tailored to the needs of the individual. This apparently simple and uncontentious statement turns out to have complex and far-reaching implications for the delivery of clinical interventions. It is essential, for instance, that a thorough assessment should identify, for each individual case, the nature of the problem and appropriate and achievable goals for treatment. In addition, the treatment process. should identify as early as possible those particular factors that are likely to assist or. hamper the achievement of the treatment goal(s). Examples of types of treatment goals might include the following: (1) Reduction of psychological, social or other problems not directly related to the use of drugs. (2) Reduction of psychological, social or other problems related to the use of drugs. (3) Reduction of harmful or hazardous behaviour associated with the use of drugs. (4) Attainment of controlled, non-dependent, or nonproblem drug use. (5) Attainment of abstinence from the problem drug. (6) Attainment of abstinence from all drugs. These six examples are not mutually exclusive; (eg treatment goals may include the attainment of abstinence and the improvement of psychosocial functioning in areas unrelated to drug taking). The diversity of problems and responses has bpen acknowledged by a-.committee of the United States Institute of Medicine"' which was convened to examine treatment responses for the treatment of alcohol problems (though their comments apply equally well to drug problems). The committee observed that questions about treatment might be framed in the following manner: Which kinds of individuals, wit-h what kinds of ... problems, are likely to respond to what kinds of treatments by, achieving wbat kinds of goals when delivered by which kinds of practitioners? Only by asking specific and precisely defined questions about treatments for drug problems can we hope to achieve a better understanding of these issues. However, if it is accepted that no single treatment will be universally effective for drug dependeneeand that a range of different interventions will be required, this challenges many of the existing service delivery systems which tend to offer a fixed package of treatment components. This Procrustean system expects

Treatment

Psychological

Social

Pigure 1. Outcome is affected by three types of factors. Treatment factors are only part of this matrix The psychological characteristics of the drug user and the social environment may be as important, or more important, as determinants of outcome

all patients to fit in to the services provided rather than make the adaptations and adjustments needed to identify and respond to the specific needs of the individual. The specific interventions that occur during treatment are only a part of the wide range of factors that can influence outcome. A simplified illustration ofthis is,provided in Figure 1.which shows how outcome can be affected by three different groups of factors. These may inflsence outcome either directly in their own right or through some interaction with the other factors., Social factors such as unemployment, peer and family relationships, and accommodation, can all affect the individual's chances of success. Similarly, people with drug problems differ on a number of psychological- variables that could be expected to influence their chances of giving up drugs. Edwards'2 offered a strong warning about the limitations of treatment and suggested that excessive enthusiasm about treatment effectiveness can be misguided; this enthusiasm can be 'constrained to the point of tunnel vision if it assumes that treatment influences are so paramount that all that has to be asked is "Does treatment work?" with every other influence ... discounted. . Treatment is more accurately conceived as being at best a timely nudge or whisper in a long life course.' .

Detoxfication Perhaps the least problematic phase of treatment is detoxification - the treatment of the withdrawal syndrome. Detoxification is not in itself a treatment for drug dependence, and it is seldom effective on its own in leading to long-term abstinence. Rather, it is a family of procedures for alleviating the short-term symptoms of withdrawal from dependent drug use. Various drugs can be used to treat the opiate withdrawal syndrome. The most common drug used both in north America and in the UK is methadone which is given in oral form and in gradually reducing does. In an inpatient setting methadone detoxification procedures can be effective both in terms of reducing the severity of withdrawal symptoms to a moderate and tolerable level and in terms of programme co.mpletion rates. In studies of inpatient methadone detoxification -programmes in the UK, completion rates of about between 70 and 82% have been reported.'3"4 Other drugs which have -also been commonly used include ben zodiazepines and clonidine.

Journal of the Royal Society of Medicine Volume 85 August 1992 471

There has been considerable enthusiasm for out-

fron drugs in an inpatient treatmentprogramme. The

patient detoxiflcation, and in a major review of the literature, the United States Institute of MedicineI6

study produced two mnfindingsThe bad news was that the period immediately after leaving the inpatient

noted that 'detoxification of most illicit drugs in most cases can occur as safely and effectively on an ambulatory [ie outpatient] basis as in a" bedded setting' (p. 175). However, there is very little hard evidence to support this contention. One of the few studies to compare the effectiveness of inpatient and outpatient detoxification programmes founda clear difference between the two treatment-modalities: the programme completion rate for inpatients was 81% compared with only 17%'for outpatients'6. Attemptsi have been made to improve this poor outcome rate for outpatient detoxification. -For example, 'the use of a 'flexible' reduction schedule was introduced whereby the addicts could negotiate with the prescribing doctor to increase ,or; decrease thexrate at which dose reductions orcurred'7. This failed to produce any improvement in outcome when compared with the use of a 'fixed' withdrawal schedule; both,,groups continued to do badly with very few subjects completing the detoxification programme successfully. Because physiological symptoms such as abdominal cramps, diarrhoea, and muscle spasms are a prominent feature of the opiate withdrawal syndrome, and possibly also because its treatment usually involves the administration of drugs, detoxification has often been regarded primarily in physical terms, and consequently its treatment hasbeen seen primarily as a 'medical' procedure. None the less, there is ample evidence to demonstrate the impact of social and psychological factors upon the withdrawal syndrome. Many addicts report feeling frightened of the prospect of withdrawal, and the anxieties and expectations of the addict have been found to be important determinants of the severity of the withdrawal symptoms that the addict experiences during detoxification18. This finding has direct clinical implications. The severity of withdrawal distress among inpatient opiate addicts can be reduced by providing them with accurate and reassuring information about the withdrawal treatment and the type of withdrawal symptoms that they could expect19.

treatment programme was a time during which there was a very high risk of returning to drug taking. Within one week of leaving the unit 42% ofthesample had used opiates on at least one occasion, and within six weeks of discharge, 71%.had used opiates. The first few weeks after discharge were a -critical period in terms of the individual's chances of staying off drugs. However, this finding must be offset by some good

The problems of relapse Only relatively recently has it become clear what happens to people after they have been treated for problems of drug dependence. The first prospective study of its kind in the UK14 followed up a group of 80 opiate addicts who had been sucfully withdrawn

news. The first lapse to opiate use did not herald a fullblow*i relapse to addiction. There)rwas- a 'recoveryafter-lapse' effect which has not been shown in those studies which have used the initial lapse to drug taking as an outcome measure (to indicate failure). In the ,6 months after leaving- treatment there was a gradual -increase in the number of people who were abstinnt from opiates which included many of those who had.used drugs immediately after treatment. Six months after discharge+ about half of the sample were abstinent with no signs of having substituted bther forms ofdrug taking for their prior opiatedependence (see Figure 3). This Maudsley Relapse Study should not be interpreted as a treatment evaluation study. It was not designed for this purpose. Instead it was designed to look at the social, interpersonal, psychological. and environmental factors that were associated with relapse (or survival) among opiate addicts after treatment. Among the more prominent relapse factors identified were negative mood states, such as boredom and anxiety; cognitive factors, including deliberate decisions to' use again; and a range of environmental factors, including unsatisfactory- home environments20. One of the' strongest predictors of good outcome was the number of protective factors in the person's environment; ie any persons, activities or social structures, which were identified by the individual as being helpful to them in their efforts to stay off drugs21. Even though the Maudsley Relapse Study was not designed to detect the impact of treatment, it is interesting that a treatment effect was found among the factors that were predictive of outcome at 6 months. The addicts who completed the treatment programme or who remained in treatment for longer periods were most likely to be drug free 6 months later. On its own, this length of stay effect may be interpreted in a number of ways and it must be treated with some caution before it can be accepted 100.

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472

Journal of the Royal Society of Medicine Volume 85 August 1992

as indicating an effect of treatment. However, the same effect has been reported in many other studies, including the massive Treatment Outcome Prospective (TOPS) carried out in the United States with a sample of more than 11 000 people and a follow-up extending to 5 years22. The TOPS study concluded that their three treatment modalities led to significant decreases in heroin use with time in treatment as one of the most important predictors of post-treatment heroin use. As in the Maudsley study abstinence rates averaged 40-50%. A committee on drug abuse convened by the US Institute of Medicine15 concluded that although there are marked variations in the responses of individuals to different treatment methods and in the results obtained by different programmes, 'Treatment reduces the drug consumption and other criminal behaviors of a substantial number of people'. The committee also noted that although the precise effects of treatment were difficult to specify '. . . length of time in treatment is a very important correlate of outcome.' These conclusions and an increasing weight of careful research evidence stand in marked contrast to the pessimistic attitudes of the 1960s and 1970s. References 1 Einstein S. The narcotics dilemma: who is listening to what? Int J Addict 1966;1:1-6 2 Callahan E. Alternative strategies in the treatment of narcotic addiction. In: Miller W, ed. The addictive behaviors. Oxford: Pergamon, 1980 3 Thorley A. Longitudinal studies of drug dependence. In: Edwards G, Busch C, eds. Drug problems in Britain: a review of ten years. London: Academic Press, 1981 4 Stimson G, Oppenheimer E. Heroin addiction: treatment and control in Britain. London: Tavistock, 1982 5 Robins L. The Vietnam drug user returns. Washington DC: Government Printing Office, 1973 6 Schachter S. Recidivism and self-cure of smoking and obesity. Am Psychol 1982;37 :436-44 7 Saunders W, Kershaw P. Spontaneous remission from alcoholism - a community study. Br J Addict 1979; 74:251-6

Which treatments work for alcohol-related problems

B Ritson FRCP FRCPsych Department ofPsychiatry, Alcohol Research Group, University of E4inburgh, Morningside Park, Edinburgh EH10 5HF Keywords: alcoholism; alcohol-related problems

Introduction The range of treatments, therapies and stratagems offered to individuals experiencing alcohol related problems is both impressive and disturbing, impressive

8 Biernacki P. Pathways from heroin addiction. Recovery without treatment. Philadelphia: Temple, 1986 9 Gossop M, Battersby M, Strang J. Self-detoxification by opiate addicts: a preliminary investigation. Br J Psychiatry 1991;159:208-12 10 Gossop M. What is the most effective way to treat opiate addiction? Br J Hosp Med 1987;38:161 11 US Institute of Medicine. Broadening the base of treatment for alcohol problems. Washington: National Academy Press, 1990 12 Edwards G. As the years go rolling by. Drinking problems in the time dimension. Br J Psychiatry 1989; 154:18-26 13 Gossop M, Griffiths P, Bradley B, Strang J. Opiate withdrawal symptoms in response to 10-day and 21-day methadone withdrawal programmes. Br J Psychiatry 1989;154:360-3 14 Gossop M, Green L, Phillips G, Bradley B. Lapse, relapse and survival among opiate addicts: a prospective followup study. Br J Psychiatry 1989;154:348-53 15 US Institute of Medicine Treating drug problems, vol 1. Washington: National Academy Press, 1990 16 Gossop M, Johns A, Green L. Opiate withdrawal: inpatient versus outpatient programmes and preferred versus random assignment to treatment. BMJ

1986;293:103-4 17 Dawe S, Griffiths P, Gossop M, Strang J. Should opiate addicts be involved in controlling their own detoxification? A comparison of fixed versus negotiable schedules. Br J Addict 1991;86:977-82 18 Phillips G, Gossop M, Bradley B. The influence of psychological factors on the opiate withdrawal syndrome. Br J Psychiatry 1986;149:235-8 19 Green L, Gossop M. The effects of information on the opiate withdrawal syndrome. BrJ Addict 1988;83:305-9 20 Bradley B, Phillips G, Green L, Gossop M. Circumstances surrounding the initial lapse to opiate use following detoxification. Br J Psychiatry 1989;154:354-9 21 Gossop M, Green L, Phillips G, Bradley B. Factors predicting outcome among opiate addicts after treatment. Br J Clin Psychol 1990;29:209-16 22 Hubbard R, Marsden M, Rachal J, Harwood H, Cavanaugh E, Ginzburg H. Drug abuse treatment. Chapel Hill: University of North Carolina Press, 1989

(Accepted 12 September 1991)

in providing evidence of the effort, ingenuity and Paper read to endeavour which has been applied to this problem - joint meeting of one reviewer of the treatment literature, for example, Sections of found that it required 6 months to read the scientific Epidemiology & Health literature on treatment evaluation', disturbing Public Psychiatry because there is no consensus about optimum and 13 February 1991 treatment approaches. Reviews of the treatment literature reveal an unsettling paradox whereby treatments that often enjoy greatest popularity are least supported by research evidence while those approaches which often h:ave proven merit remain less popular. There is an-urgent need to overcome the entrenched positions 0141-0768/92 that have been taken in some countries between 080472-05/$02.00/0 experienced practitioners and equally committed © 1992 research workers. I believe that there is now evidence The Royal of rapprochement, often with a recognition that Society of differences which seemed insurmountable are based Medicine

Addiction: treatment and outcome.

Journal of the Royal Society of Medicine Volume 85 August 1992 469 Substance Abuse Addiction: treatment and outcome M Gossop PHD FBPsS Drug Depende...
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