Narcotic Antagonists and the ParoleeOutcome, Issues, and New Directions Thomas E. Hanlon and 0. Lee McCabe
I
N A MYRIAD OF CURIOUS and ironic ways, the treatment of the addicttparolee with a narcotic antagonist is an anomaly in the practice of medicine. It entails the prescription of medication to individuals who have not actively sought treatment of their own accord, who frequently do not consider themselves sick, and whose symptoms and clinical course are, for the most part, measured in societal rather than medical terms. Invariably. treatment evaluations are primarily concerned with behavioral criteria of effectiveness such as extent of narcotic drug use and length of program participation. Emphasis is placed on maintaining the addict free of opiate drugs by the prescription of antagonists, with the presumption that he will thus be better able to readjust to the demands of free society and to make maximum use of rehabilitative resources that are available. In forestalling opiate use, there is also the more likely avoidance of hepatitis and other sequelae of self-administration, including death from overdose, and the possible curtailment of criminal and other illegal activities associated with supporting a narcotic drug habit. But how well do the antagonists forestall compulsive opiate use? NATURE AND APPROPRIATENESS
OF TREATMENT
The effectiveness of narcotic antagonists as a deterrent to the narcotic drug use of addict&parolees still requires verification. There is little question as to their ability to block the euphoric and analgesic effects produced by opiates. Their use. for instance, in the treatment of narcotic drug overdose and as an aid in the diagnosis of opiate dependence hardly requires demonstrating. It is when they are used prophylactically, i.e., to prevent addiction, that issues regarding appropriateness and effectiveness arise. In this context, one of the foremost issues relating to the parolee appears to be the possible administration of medication against an individual’s will or as the sole alternative to punitive or restrictive measures enforced by society. The remanding of an individual at odds with society to a designated treatment regimen is not without precedent. Many “problem drinkers” have had to undergo treatment or attend educational programs on alcoholism as a requisite for remaining in free society. And a type of coercion is involved in those situations in which From the Marvland Psychiatric Research Center. Department of Psychiatry. University ol Manland Medical School. Baltimore, Md. Thomas E. Hanlon, Ph.D.: Research Associate; Lee McCabe, Ph.D.: Research Associafe; Deparrment of Psvchiatry, Mar_vland Psychiatric Research Cenler. llniversit~ of Marvland School of Medicine. Baltimore, Md. Reprinr requests should be addressed to Thomas E. Hanlon. Maryland Psychiatric Research Cenrer. Departmenl of Psychiatry, University of Maryland School of Medicine. Baltimore, Md. 21228. Supported in part by NIDA Drug Abuse Center Grant DA-00415. administered by Friend.7 Medical Science Research Center. Inc., Cantonsville. Md. c 1978 bv Grune & Stratton, Inc. ISSN 0010-440X. 0010 440.U/7~/190l~0005~02.00/0/
Com~rehensrve Psychiatry, Vol 19. No 1 (January/February).
1978
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alcoholics are committed to disulfiram (Antabuse, Ayerst, N.Y.C., N.Y.) programs by the courts, or the use of this particular drug is made a condition for probation or parole. In describing one such program in Wisconsin, Kimmel states, “It is important to note that no one is forced to take medication against his will. He always has a choice-taking the medication or serving his sentence.“’ There are other medical-legal precedents as well. Unless he submits to a medically approved maintenance program, for example, an epileptic or a diabetic must forfeit participation in certain activities that present a clear danger to himself and other members of society. To our knowledge, however, no one has ever been legally required to take an experimental medication as a condition of remaining in free society. Because narcotic antagonists are experi~nental, their use in maintenance treatment programs necessarily involves formal evaluation of safety and effectiveness and adherence to procedures designed to protect the rights and welfare of individuals involved in human experimentation. Consent to participate in such a program must be both voluntary and informed. In this process it is important that the parolee be offered a fair explanation of narcotic antagonist treatment and be assured of the availability of alternative treatment should he decide against the reception of a narcotic antagonist. It should also be made clear that agreeing to the reception of medication is not, and cannot be, a condition of parole and that even if he initially agrees to receive medication, he may subsequently reverse this decision at any time. Despite what appear to be desirable supportive advantages, narcotic antagonist treatment is not especially popular among newly released parolees, who often express the conviction that they will never resort to narcotics use again. For a variety of reasons, many parolees enrolled in urine-monitoring programs do not wish to take medication of any kind. Among those who are sincerely motivated to remain narcotic drug-free, most refuse medication, preferring to rely initially on their own self-discipline. The intractable individual understandably refused medication because he wants no part of a treatment regimen that will deny him the pleasure afforded by narcotics. The problem is, unfortunately, that there is presently no foolproof way to differentiate the truly motivated individual from the recalcitrant beyond the gathering of subsequent evidence of abstinence program participation. Some parolees will obviously require little or no treatment involvement, while others will demonstrate a consistent need for external support in the readjustment process and in the avoidance of narcotic addiction. It appears that in spite of the lack of unequivocal evidence of prior dependence” and in spite of protestations to the contrary, addict-parolees are likely to resort to narcotic drug use once they are released to the community.” During the first five years of operation of our outpatient narcotic clinic in Baltimore, 371 opiate abusers released on parole from the correct;onal institutions of Maryland were referred to the clinic’s abstinence program. Of these 371 referrals, 85% used illicit narcotics within 12 weeks of their release from prison, and another 10% used narcotics before the termination of their parole. Only 5% of those in the program remained abstinent during their entire parole supervision, which, in all cases, involved periods under 18 months. More recent data on 262 referrals to the same clinic revealed a deviation rate of approximately 80% within the first nine months of program participation.
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49
AND THE PAROLEE
Judging from background and personal characteristics and from the adversities they subsequently experience, there is a great likelihood of further illegal activity on the part of parolees once they have resorted to narcotic drug use. Most have a long history of frequent arrests and convictions, have marginal adjustment records in the formal educational system, and have typically been unable to maintain steady employment for more than comparatively brief periods. Reflecting this maladaptive behavior, mean psychometric profiles for these individuals have been found to be indicative of sociopathic, emotionally unstable personalities and as characteristic of individuals who, though often superficially friendly, outgoing, and likeable, tend to be self-centered, impulsive, and rebellious, and to lack a high standard of morality.4.5 Added to these predispositional factors are the ~~verwhelming cost of procuring narcotic drugs in the streets and a near-indigent financial status that is subject to further deterioration as a habit develops.” Referring again to the 371 addict parolees processed through our abstinence program over a five year period, 80% failed to complete their paroles satisfactorily. Most absconded or were institutionalized for commission of another felony or for detoxification, which was followed by readdiction in 90% of the cases. Of those who absconded, a fairly high proportion were addicted at the time they left the program. When we introduced the use of narcotic antagonists into this program, we were, obviously, dealing with a population-at-risk. ANTAGONIST
TREATMENT
CHARACTERISTICS
As for the prophylactic use of a “pure” antagonist, i.e., one having no agonistic effects of its own, there is no pharmacologic reason to expect that the administration of such an agent will insure complete abstinence since it does not reduce the urge to take narcotics. The only initial deterrent to narcotic drug-seeking behavior is the expectation on the part of the addict that he is unlikely to experience his customary “high” when he resorts to narcotic drug use. Under the circumstances, complete abstinence from narcotics use on the part of the paroled addict is an unrealistic and inappropriate goal of treatment. It is important, therefore, that the maintenance of complete abstinence be recognized as a measure of placebo reactivity (including the notion that it would be futile to “fire” under the circumstances) and/or a high level of patient motivation rather than as a meaningful criterion of the effectiveness of a particular antagonist under investigation. The evaluative issue as far as an antagonist is concerned is whether it has an extinguishing effect on subsequent narcotic drug-taking behavior once narcotics are resumed. Correspondingly, the most meaningful criterion of effectiveness is measurement of the extent of narcotic drug use after the first deviation. Unlike insulin and similar regulatory agents, narcotic antagonists do not rectify a naturally occurring imbalance within the body. Hypothetically having a greater affinity for narcotic receptor sites than presently known narcotics, narcotic antagonists thus exert both an immediate and remote regulatory action when narcotics are subsequently introduced into the system. As indicated above, their immediate action is that of blocking the typical “high” experienced when narcotics are taken within variously limited time spans. On continued administration, their more remote regulatory action is the prevention of physical dependence. The use of the narcotic antagonist approach to prevent addiction is based on the hypothesis that the elimination (by the blocking effects of antagonists) of a rein-
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forcement or reward (euphoria, etc.) following a particular behavior (narcotic drug intake) will result in a decrement in that behavior and, eventually, in its elimination. In actuality, however, it is impossible to extinguish a response, within the context of our particular ethical system, when an individual is aware of the extinction process and is not in continued agreement with its need or application in his particular case. Herein lies the Achilles’ heel of the approach. Whenever an individual wishes to receive his customary reinforcement from narcotics use, he simply avoids antagonist medication, thereby ultimately setting up his own reinforcement schedule wherein avoidance of medication becomes the conditioned response. ANTAGONIST
TREATMENT
EVALUATION
Outcome Narcotic antagonists have been used clinically for the past several years in spite of the paucity of controlled tests of efficacy. From the beginning, there seemed to be a universally held assumption that except for side effects, which until the introduction of naloxone and naltrexone had been their principal drawback, there was little question as to the utility of narcotic antagonists. More recently, this assumption has been challenged, both in clinical practice and in controlled studies designed to isolate their pharmacological contributions beyond that of placebo reactivity. Prior to the more general use of the narcotic antagonists, the present authors participated in a long-term objective evaluation of a community-based abstinence program for addicts paroled from correctional institutions within the State of Maryland. This evaluation afforded extensive clinical experience with the opiate abuser in a program incorporating weekly group psychotherapy, a high level of parole supervision, and daily urine monitoring.” It was with such a baseline as a frame of reference that a series of studies was subsequently undertaken in the same setting to explore the efficacy of the administration of narcotic antagonists on a daily and “contingent” (upon evidence of narcotic drug use) basis. Superimposed on the already existing abstinence program, the narcotic antagonist research program extended over a six year period.7.x The first two studies of the program involved successive pilot and double-blind, controlled evaluations of the effectiveness of daily administered, low dose naloxone (Z~-800 mg), considered a partial or brief bIockade.g.‘v Two subsequent studies invoIved successive pilot and double-blind, controlled assessments of the effectiveness of higher dosage naloxone (500-2000 mg daily) administered on a contingent basis.*1,12A fifth study in the series was a double-blind, controlled evaluation of the comparative effectiveness of contingently administered, high dosage naloxone vs daily administered cyclazocine (up to 4 mg).‘” Regarding the typical reaction of the addict-parolee to narcotic antagonist medication, administered under both daily and contingent conditions, the results of our open and controlled studies to date have shown that the extent of nonspecific, or placebo, effects is quite remarkable. Convincingly demonstrating the superiority of a narcotic antagonist over its corresponding placebo under such conditions was, understandably, a more difficult task than we had first imagined. The mere taking of oral medication, even though inactive, apparently had a beneficial
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effect in terms of program retention and outcome. For example, in our controlled comparison of randomly assigned placebo and routine treatment (no medication) groups, both of which received parole supervision and group psychotherapy,“’ respective completion rates over a nine month treatment period were found to be 50% versus 259’0, indicating in this one instance. at least, a twofold advantage in favor of inactive oral medication. Even the addict’s knowledge that he will be administered an antagonist if he deviates appears to have a deterrent effect on narcotics use (which must be controlled for in evaluative research). In our program of research, six month outcome data on 108 addict-parolees participating in a contingent naloxone pilot study” revealed that 37% of the sample maintained complete abstinence and were, therefore, not administered antagonist medication. Previous results in the same setting with the nonchemotherapy sample of 371 abstinence program parolees having essentially the same prognostic characteristics had revealed only a 12% complete abstinence rate. Controlling for nonspecific reactivity, we were still able to identify two consistent responses to narcotic antagonists: a slight, though repeatedly discernible, decrease in narcotic drug use; and a consequent maneuvering to avoid medication, either intermittently or permanently. Although associated with less narcotic drug use, active medication showed no added benefit over placebo in terms of length of program participation or final disposition, which are generally considered the crucial criteria of effectiveness. Our findings have consistently suggested a relationship between avoidance, or refusal, of medication and the narcotic blocking capabiIity of the active agent. In our most recent report\“) on the contingent use of the antagonist naloxone with the addict--parolee, which we subtitled “The Failure of an Effective Approach,” we make the paradoxical point that effectiveness as an antagonist may preclude successful treatment outcome. Results of our double-blind, controlled study indicated that there was little reason to doubt that naloxone successfully blocked the euphoric and analgesic effects produced by opiates, thereby reducing the parolees’ incentive to use narcotics while medicated, Rather than inhibiting the drug-taking behavior of less motivated addict-parolees, however, the principal effect of naloxone appeared to be that of reinforcing avoidance of medication and indulgence in otherwise uncooperative behavior. It appears that motivation is a key determinant in the success of the antagonist approach with the addict-parofee. In the properly motivated parolee, the use of the approach can provide an important buffer to the process of readdiction. Although there are vital differences, in many respects the antagonist approach to the addict- parolee appears to be what Antabuse administration is to the alcoholic.” Just as Antabuse is now regarded as an adjunct to alcoholism treatment rather than the focus of therapy, the promise of antagonists appears to be principally in the adjunctive management of selected narcotic addicts who desire assistance in maintaining a state of abstinence so that supportive and psychotherapeutic resources can be utilized to advantage.
The conduct of our research over the years was not without the confrontation and, we hope, resolution of a number of emergent ethical and logistic issues.
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How, for example, can one guarantee the rights and welfare of an individual in an experimental situation involving both parole supervision and medical maintenance? Since a parolee’s rights are already severely restricted, is such an individual really free to discontinue treatment of his own accord, and if he does, what are the consequences? In our opinion, there is simply no debating the underlying issues here. No matter what his civil status may be, safeguarding the psychologic and physical integrity of an individual is an obligation in every research endeavor, even if doing so jeopardizes the research efforts or limits the generalization of results. Although he may be required to remain in a drug abuse treatment program of one kind or another, in a free society such as ours, a parolee, or any other individual for that matter, cannot be forced to take experimental medication against his will. Therefore, should he choose to discontinue such medication, he must be able to do so without prejudice to his parole status and without relinquishing any of his already limited rights. In comparative evaluations, research objectives are not entirely lost, however, if a parolee refuses to continue medication, since frequency and patterns of refusals may reveal differential information about the various treatments under study. Refusal to continue medication cannot only be utilized as a meaningful criterion of treatment effectiveness in itself, but can also provide a useful basis on which to categorize patients for follow-up evaluation purposes. For example, we have found that after they resumed narcotic drug use, parolees were more likely to refuse to continue experimental medication administered under double-blind conditions if they were receiving an active antagonist substance than if they were receiving placebo. And on follow-up evaluation, those parolees who had earlier refused medication were more likely to show evidences of general maladjustment and of narcotic drug use, in spite of continued involvement in the same abstinence program, than those who completed the prescribed medication schedule.12 There was another type of experimental subject attrition that we encountered that is unique to controlled studies of the narcotic antagonist approach. Unfortunately, not every subject chosen and treated in a narcotic antagonist program can be utilized in the evaluation process. Curiously, it is those who maintain complete abstinence through the medication period about whom we can say the least as far as treatment response is concerned. As paradoxic as it may sound, determining the effectiveness of a narcotic antagonist cannot be accomplished without narcotic drug use having occurred during treatment, It is not until the parolee-addict deviates that the impact of active medication can be measured and differentiated from the nonspecific (placebo) effects of taking a pill that allegedly blocks narcotic effects. The maintenance of complete abstinence on the part of the addict-parolee tells us little regarding the antagonist properties of a given agent in question and little to nothing about permanent extinction of drug-seeking behavior. Another logistic problem faced by antagonist researchers is common to all early drug evaluations. It is a well-known phenomenon that experimental procedures such as increased attention, more frequent patient contact, etc., have biasing effects on the measured outcome of an ~tervention, as dramatically illustrated by the often cited “Hawthorne effect.” In clinical research, artifactual effects are frequently positive ones, contributing to the attainment of improvement t’ates in excess of those ordinarily expected under routine conditions. That
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such effects are operative in narcotic antagonist research is obvious from our previous discussion. A less obvious experimentally induced artifact that precludes optimal effectiveness in early narcotic antagonist trials arises from the need for what under routine clinical conditions would be considered an jnordjnate amount of laboratory tests. Frequent and varied assays are admitt~Iy criticat during the preliminary stage of drug investigation since the purpose of early clinical trials is to obtain both drug dosage and human safety information. They do, however, represent a difficulty for the addict and undoubtedly contribute to lower treatment acceptability and more frequent dropouts, reactions that must be considered when evaluating the potential usefufness of newer narcotic antagonists subject to Phase IT experimentation, Neu! Directions One of the principal drawbacks to presently available narcotic antagonists is their short duration of action. Until the pharmacologic action of these agents can be suRcientty extended to minimize the addict-parolee’s capabibty of titrating his own medication intake, the value of the antagonist maintenance approach in any given case depends primarily on the consistency of the motivational level of the individual. For more general application, the biodegradable, sustained-release delivery system for a narcotic antagonist appears to hold special promise. Understandably, such complete control over another’s life by chemical means necessarily requires careful examination of important ethical issues reiating to individual freedom. More than ever, it would be imperative that treatment be entered into voluntarily only after self-acknowledged need and a verified awareness of available alternate treatments. Also, there should be full awareness of the restrictiveness and possible consequences of prolonged treatment effects. One obvious advantage of such precautionary measures woutd be that the less motivated parolee would more likely be identified prior to treatment rather than at an intermediate phase, thus saving both him and the treatment team subsequent frustration and disappointment. Granting a bewildering array of causative factors, compulsive narcotics use by addicts is at least partially attributable to diffuse ~sychophysioiog~ca~ discomfort, the alleviation of which is a signiticant reinforcer. TheSaiIureqffAezrorhPra~ellric intervention to deal direct/y with such discomjkt wii( irtevitabl_vresult in limited applicability and effectiveness. It is primarily for this reason that pure antagonists
do not seem to offer significant rehabilitative promise for the typical parolee or street addict. For many such individuals, there is simply no incentive or reward in the taking of a chemical that denies them the relief or comfort they obtain from narcotics. fn view of this, it seems advisable to supplement the search for pure narcotic antagonists with the search for antagonists with non- or minimally addicting agonistic properties, The combined use of an antagonist and a neuroleptic also appears to be an approach worthy of pursuit. Judiciously used during the early stages of parole, when stresses are maximal, the clinical use of new and/or combined agents might sustain the participation of less consistentty motivated addicts in therapeutic endeavors they might otherwise find tedious. As we have expressed elsewhere,’ innovative approaches to the treatment of the
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addict-parolee must be pursued to insure further progress in this area, One such approach is that of the combination of brief, drug-assisted psychotherapy with the narcotic antagonist model. A locally conducted series of controlled studies of drug-assisted psychotherapy employing lysergic acid d~ethylamide (LSD) and dipropyitryptamine (DPT)‘5-“’ suggested that rapidity of therapeutic impact may be one of the principal virtues of this intensive form of treatment, especially with addictive disorders. Apparently, within a matter of a few weeks persisting depression can be relieved, generalized anxiety and preoccupying distress reduced, and constructive motivation established. Another advantage is the apparent effectiveness of this type of therapy with culturally deprived patients who tend to score low on standard tests of intelligence and who would ordinarily be considered poor candidates for conventional therapy. Judging from our experience, the route to emotional reeducation represented by the method does not seem prejudiced against individuals lacking in verbal skills or sophistication. Additionally, other patients considered exceedingly difficult or inappropriate candidates for conventional treatment by virtue of their inability to enter into a therapeutic relationship (e.g. sociopathic and other personality disorders) can apparently be engaged by the brief, intensive procedures involved and continue meaningfully and effectively in therapy. Although found to be of demonstrated effectiveness with narcotic addicts,‘” drug-assisted psychotherapy is an essentially short-term, time-limited experience that cannot realistically be expected to sustain behavioral redirection and symptom control indefinitely. Narcotic antagonists, on the other hand, show promise in controlling narcotic drug use but do not alter root defects or conflicts in the personality system. Because the deficiency of each of these treatments is the particular strength of the other, it seems reasonable to postulate that a combination of the two might provide a new and effective treatment approach to the narcotic addict. SpecificaHy, brief, intensive psychotherapy, employing a short-acting agent such as DPT, followed by a maintenance course of the narcotic antagonist naltrexone2’ might be capable of effecting personality change and symptom control in those addict-parolees who seem refractory to all forms of therapeutic management short of sustaining their addiction with synthetic opiates. A PROPOSED
HIERARCHY
OF ADDICTION
TREATMENTS
Various approaches to the treatment of narcotic addiction, such as methadone and LAAM (I-alpha-acetylmethadol) maintenance programs, therapeutic communities, abstinence programs, and administration of narcotic antagonists, may be hierarchically conceptualized as offering increasing levels of difficulty for patient compliance and demanding successively greater degrees of patient motivation for satisfactory participation. 23 Methadone maintenance, for example, may be viewed as occupying the bottom position in the hierarchy of current treatments in that it allows the addict to continue daily narcotic consumption, thereby offering less difficulty for compliance and demanding relatively little motivation for continued program participation. (in this schema, LAAM maintenance would be considered as occupying a slightly higher position since longer-acting LAAM is less euphorigenic than methadone.) At the opposite extreme, an abstinence program represents a comparatively difficult approach for the addict (especially
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when applied with relatively few supportive services) and demands a high degree of motivation for successful participation. Since the attainment of complete abstinence in such a program is unlikely and since relapse to drug use is usually equated with program failure, the abstinence approach may be seen as occupying a position near the top of the hierarchy. Compared to these two extremes, a middle position seems appropriate for therapeutic communities, which typically demand abstinence of their residents but provide a fairly substantial degree of control and interpersonal support. As for the modality of more immediate interest, i.e., the administration of narcotic antagonists, indications as to where this fits into this conceptual framework and what may be expected from the use of these agents in terms of program retention and completion rates are currently emerging from early clinical studies and controlled research. Even though it is an alleged conditioning procedure involving the prescription ot medication, the narcotic antagonist approach is essentially another version of the abstinence approach, demanding the same patient characteristics for successful application. In view of the fact that the prescription of pure antagonists provides no directly pleasurable or ameliorative effect, the approach, as currently employed, earns a position near the top of the hierarchy. The unremarkable therapeutic results obtained in controlled evaluative research on the use of antagonists with unmotivated addicts is certainly not surprising. With such patients, there is little reason to expect the achievement of outcome results superior to any other abstinence program with the same underlying supportive services, including the administration of inactive medication. Since treatment modalities that demand abstinence are much more difficult for patient compiiance than those that do not (all other things being equal), abstinence programs cannot be expected to compete with maintenance approaches in retaining large groups of unselected addicts in treatment. Accordingly. the failure rates of the various types of treatment, from maintenance to abstinence. reflect the number of addicts who are “over their heads” in terms of the treatment hierarchy and who might do better in a lower level modality. Within the logic of this schema, it is inappropriate to ask if one treatment is better than another without considering patient readiness for treatment. It is not simply a question, for example of whether agonists are better than antagonists; one must ask the additional question: For what type of patient? Thus considered, one treatment is more suitable than another at different points along the continuum of treatment readiness. Should one treatment fail in a given case, another one lower in hierarchic order may be indicated. And following the same logic, should treatment at the lower end of the continuum be successful, the next step in the progression from opiate drug dependence to abstinence is the subsequent employment of a higher order treatment approach. Viewing the above information in the context of our present concern with the addict- parolee, it is our contention that most of these individuals are “over their heads” in the narcotic antagonist approach, and the fact that they do not do well in treatment tells us more about them than about treatment efficacy. Unfortunately, for the majority of addict--parolees, the administration of a narcotic antagonist is a treatment technique requiring more personal responsibility and motivation than such individuals possess at this point in their lives.
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ACKNOWLEDGMENTS The authors wish to express their appreciation to Friends Medical Science Research Center, Inc. for a~inistering the various projects involved in the narcotic antagonist program and to Dr. Albert A. Kurland, who initiated the overalt research effort. Most of the research cited was funded as part of NIDA Drug Abuse Center Grant DA-00415, the Principal Investigator of which was Dr. Charles Savage. The Maryland Drug Abuse Administration, Department of Health and Mental Hygiene, supported the underlying clinical program. Urine analyses were conducted by the Drug Abuse Laboratory, Friends Medical Science Research Center, Inc., under the direction of Dr. Robert Kokoski. In addition to the Narcotic Clinic Staff, under the direction of Ms. Bonnie Charyszyn, the help of the following individuals is gratefully acknowledged: Dr. Robert J. Blatchley, Ms. Hazel Bohmer, Mr. Steven F. Curran, Dr. Vasilios Frankos, Ms. Dorothy Sullivan, and Ms. Edwina Wilkinson. REFERENCES 1. Kimmel ME: Treatment of alcoholics in a correctional setting. Paper presented at the 23rd Annual Meeting of the Alcohol and Drug Problems Association of North America, Atlanta, Georgia, September, 1972 2. Nurco DN, Lerner M: Characteristics of drug abusers in a correctional system. J Drug Issues 2:49, 1972 3. McCabe OL, Kurland AA, Sullivan D: Paroled narcotic addicts in a verified abstinence program: Results of a 5-year study. Int J Addict 10:211, 1975 4. Marks PA, Sieman W: Actuarial Description of Abnormal Psychology. Baltimore, Williams & Wilkens, 1963 5. Gilberstadt H, Duker J: Handbook for Clinical and Actuarial MMPI Interpretation. Philadelphia, Saunders, 1965 6. Nurco DN, Farrell EV: Narcotic abusers and poverty. Criminology 13:389, 1975 7. Kurland AA, McCabe OL, Hanlon TE: Contingent naloxone (N-allylnoroxymorphone) treatment of the paroled narcotic addict. Int Pharmacopsychiatry 10: 157, 1975 8. Hanlon TE, Kurland AA, McCabe OL: Naloxone treatment of the paroled narcotic addict: A program of research, in Singh S (ed): Drug Addiction: Neurotherapy and Other Treatments, vol5, 1977 (in press) 9. Kurland AA, Krantz JC, Henderson JM et al: Naloxone and the narcotic abuser. A low dose maintenance program. Int J Addict 8: 127, 1973 10. Kurland AA, Hanlon TE, McCabe OL: Naloxone and the narcotic abuser: A controlled study of partial blockade. Int J Addict 9:663, 1974 1I. Kurland AA, McCabe OL, Hanlon TE: Contingent naloxone treatment of the narcotic addict: A pilot study. Int J Addict I 1:13I, 1976 12. Hanlon TE, McCabe OL, Savage C et al: Narcotic antagonist treatment of ad-
diet-parolees-The failure of an effective approach. Compr Psychiatry 18% l-220,1977 13. Hanlon TE, McCabe OL, Savage C, et al: A controlled comparison of cyclazocine and naloxone treatment of the paroled narcotic addict. Int Pharmacopsychiatr l&240, 1975 14. Doherty J: Disulfiram (Antabuse): Chemical commitment to abstinence. Alco Health Res World, Spring, 1976 15. Pahnke WN, Kurland AA, Unger S, et al: The experimental use of psychedelic (LSD) psychotherapy. JAMA 212:1856, 1970 16. Kurland AA, Savage C, Pahnke WN, et al: LSD in the treatment of alcoholics. Pharmakopsychiatr Neuropsychopharmakol 4:83, 1971 17. Savage C, McCabe OL, Kurland AA, et al: LSD-assisted psychotherapy in the treatment of severe chronic neurosis. J Altered States Consciousness 1:31, 1973 18. Savage C, McCabe OL: Psychedelic therapy of drug addiction, in Brown C, Savage C (eds): Drug Abuse Controversy. National Educational Consultants, Baltimore, 1972 19. Savage C, McCabe OL: Residential psychedelic (LSD) therapy for the narcotic addict. A controlled study. Arch Gen Psychiatry 28:808,1973 20. Grof S, Soskin RA, Richards WA, et al: DPT as an adjunct in psychotherapy of alcoholics. Int Pharmacopsychiatry 8:104, 1973 21. Soskin RA, Grof S, Richards WA: Low doses of dipropyltryptamine in psychotherapy. Arch Gen Psychiatry 28:817, 1973 22. Martin WR, Jasinski DR, Mansky DA: Naltrexone, an antagonist for the treatment of heroin dependence. Arch Gen Psychiatry 28:784, 1973 23. McCabe OL: Heroin maintenance: An assessment of its potential role in the rehabilitation of chronic heroin abusers. Drug Forum 4:95, 1975
I
N A MYRIAD OF CURIOUS and ironic ways, the treatment of the addicttparolee with a narcotic antagonist is an anomaly in the practice of medicine. It entails the prescription of medication to individuals who have not actively sought treatment of their own accord, who frequently do not consider themselves sick, and whose symptoms and clinical course are, for the most part, measured in societal rather than medical terms. Invariably. treatment evaluations are primarily concerned with behavioral criteria of effectiveness such as extent of narcotic drug use and length of program participation. Emphasis is placed on maintaining the addict free of opiate drugs by the prescription of antagonists, with the presumption that he will thus be better able to readjust to the demands of free society and to make maximum use of rehabilitative resources that are available. In forestalling opiate use, there is also the more likely avoidance of hepatitis and other sequelae of self-administration, including death from overdose, and the possible curtailment of criminal and other illegal activities associated with supporting a narcotic drug habit. But how well do the antagonists forestall compulsive opiate use? NATURE AND APPROPRIATENESS
OF TREATMENT
The effectiveness of narcotic antagonists as a deterrent to the narcotic drug use of addict&parolees still requires verification. There is little question as to their ability to block the euphoric and analgesic effects produced by opiates. Their use. for instance, in the treatment of narcotic drug overdose and as an aid in the diagnosis of opiate dependence hardly requires demonstrating. It is when they are used prophylactically, i.e., to prevent addiction, that issues regarding appropriateness and effectiveness arise. In this context, one of the foremost issues relating to the parolee appears to be the possible administration of medication against an individual’s will or as the sole alternative to punitive or restrictive measures enforced by society. The remanding of an individual at odds with society to a designated treatment regimen is not without precedent. Many “problem drinkers” have had to undergo treatment or attend educational programs on alcoholism as a requisite for remaining in free society. And a type of coercion is involved in those situations in which From the Marvland Psychiatric Research Center. Department of Psychiatry. University ol Manland Medical School. Baltimore, Md. Thomas E. Hanlon, Ph.D.: Research Associate; Lee McCabe, Ph.D.: Research Associafe; Deparrment of Psvchiatry, Mar_vland Psychiatric Research Cenler. llniversit~ of Marvland School of Medicine. Baltimore, Md. Reprinr requests should be addressed to Thomas E. Hanlon. Maryland Psychiatric Research Cenrer. Departmenl of Psychiatry, University of Maryland School of Medicine. Baltimore, Md. 21228. Supported in part by NIDA Drug Abuse Center Grant DA-00415. administered by Friend.7 Medical Science Research Center. Inc., Cantonsville. Md. c 1978 bv Grune & Stratton, Inc. ISSN 0010-440X. 0010 440.U/7~/190l~0005~02.00/0/
Com~rehensrve Psychiatry, Vol 19. No 1 (January/February).
1978
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alcoholics are committed to disulfiram (Antabuse, Ayerst, N.Y.C., N.Y.) programs by the courts, or the use of this particular drug is made a condition for probation or parole. In describing one such program in Wisconsin, Kimmel states, “It is important to note that no one is forced to take medication against his will. He always has a choice-taking the medication or serving his sentence.“’ There are other medical-legal precedents as well. Unless he submits to a medically approved maintenance program, for example, an epileptic or a diabetic must forfeit participation in certain activities that present a clear danger to himself and other members of society. To our knowledge, however, no one has ever been legally required to take an experimental medication as a condition of remaining in free society. Because narcotic antagonists are experi~nental, their use in maintenance treatment programs necessarily involves formal evaluation of safety and effectiveness and adherence to procedures designed to protect the rights and welfare of individuals involved in human experimentation. Consent to participate in such a program must be both voluntary and informed. In this process it is important that the parolee be offered a fair explanation of narcotic antagonist treatment and be assured of the availability of alternative treatment should he decide against the reception of a narcotic antagonist. It should also be made clear that agreeing to the reception of medication is not, and cannot be, a condition of parole and that even if he initially agrees to receive medication, he may subsequently reverse this decision at any time. Despite what appear to be desirable supportive advantages, narcotic antagonist treatment is not especially popular among newly released parolees, who often express the conviction that they will never resort to narcotics use again. For a variety of reasons, many parolees enrolled in urine-monitoring programs do not wish to take medication of any kind. Among those who are sincerely motivated to remain narcotic drug-free, most refuse medication, preferring to rely initially on their own self-discipline. The intractable individual understandably refused medication because he wants no part of a treatment regimen that will deny him the pleasure afforded by narcotics. The problem is, unfortunately, that there is presently no foolproof way to differentiate the truly motivated individual from the recalcitrant beyond the gathering of subsequent evidence of abstinence program participation. Some parolees will obviously require little or no treatment involvement, while others will demonstrate a consistent need for external support in the readjustment process and in the avoidance of narcotic addiction. It appears that in spite of the lack of unequivocal evidence of prior dependence” and in spite of protestations to the contrary, addict-parolees are likely to resort to narcotic drug use once they are released to the community.” During the first five years of operation of our outpatient narcotic clinic in Baltimore, 371 opiate abusers released on parole from the correct;onal institutions of Maryland were referred to the clinic’s abstinence program. Of these 371 referrals, 85% used illicit narcotics within 12 weeks of their release from prison, and another 10% used narcotics before the termination of their parole. Only 5% of those in the program remained abstinent during their entire parole supervision, which, in all cases, involved periods under 18 months. More recent data on 262 referrals to the same clinic revealed a deviation rate of approximately 80% within the first nine months of program participation.
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AND THE PAROLEE
Judging from background and personal characteristics and from the adversities they subsequently experience, there is a great likelihood of further illegal activity on the part of parolees once they have resorted to narcotic drug use. Most have a long history of frequent arrests and convictions, have marginal adjustment records in the formal educational system, and have typically been unable to maintain steady employment for more than comparatively brief periods. Reflecting this maladaptive behavior, mean psychometric profiles for these individuals have been found to be indicative of sociopathic, emotionally unstable personalities and as characteristic of individuals who, though often superficially friendly, outgoing, and likeable, tend to be self-centered, impulsive, and rebellious, and to lack a high standard of morality.4.5 Added to these predispositional factors are the ~~verwhelming cost of procuring narcotic drugs in the streets and a near-indigent financial status that is subject to further deterioration as a habit develops.” Referring again to the 371 addict parolees processed through our abstinence program over a five year period, 80% failed to complete their paroles satisfactorily. Most absconded or were institutionalized for commission of another felony or for detoxification, which was followed by readdiction in 90% of the cases. Of those who absconded, a fairly high proportion were addicted at the time they left the program. When we introduced the use of narcotic antagonists into this program, we were, obviously, dealing with a population-at-risk. ANTAGONIST
TREATMENT
CHARACTERISTICS
As for the prophylactic use of a “pure” antagonist, i.e., one having no agonistic effects of its own, there is no pharmacologic reason to expect that the administration of such an agent will insure complete abstinence since it does not reduce the urge to take narcotics. The only initial deterrent to narcotic drug-seeking behavior is the expectation on the part of the addict that he is unlikely to experience his customary “high” when he resorts to narcotic drug use. Under the circumstances, complete abstinence from narcotics use on the part of the paroled addict is an unrealistic and inappropriate goal of treatment. It is important, therefore, that the maintenance of complete abstinence be recognized as a measure of placebo reactivity (including the notion that it would be futile to “fire” under the circumstances) and/or a high level of patient motivation rather than as a meaningful criterion of the effectiveness of a particular antagonist under investigation. The evaluative issue as far as an antagonist is concerned is whether it has an extinguishing effect on subsequent narcotic drug-taking behavior once narcotics are resumed. Correspondingly, the most meaningful criterion of effectiveness is measurement of the extent of narcotic drug use after the first deviation. Unlike insulin and similar regulatory agents, narcotic antagonists do not rectify a naturally occurring imbalance within the body. Hypothetically having a greater affinity for narcotic receptor sites than presently known narcotics, narcotic antagonists thus exert both an immediate and remote regulatory action when narcotics are subsequently introduced into the system. As indicated above, their immediate action is that of blocking the typical “high” experienced when narcotics are taken within variously limited time spans. On continued administration, their more remote regulatory action is the prevention of physical dependence. The use of the narcotic antagonist approach to prevent addiction is based on the hypothesis that the elimination (by the blocking effects of antagonists) of a rein-
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forcement or reward (euphoria, etc.) following a particular behavior (narcotic drug intake) will result in a decrement in that behavior and, eventually, in its elimination. In actuality, however, it is impossible to extinguish a response, within the context of our particular ethical system, when an individual is aware of the extinction process and is not in continued agreement with its need or application in his particular case. Herein lies the Achilles’ heel of the approach. Whenever an individual wishes to receive his customary reinforcement from narcotics use, he simply avoids antagonist medication, thereby ultimately setting up his own reinforcement schedule wherein avoidance of medication becomes the conditioned response. ANTAGONIST
TREATMENT
EVALUATION
Outcome Narcotic antagonists have been used clinically for the past several years in spite of the paucity of controlled tests of efficacy. From the beginning, there seemed to be a universally held assumption that except for side effects, which until the introduction of naloxone and naltrexone had been their principal drawback, there was little question as to the utility of narcotic antagonists. More recently, this assumption has been challenged, both in clinical practice and in controlled studies designed to isolate their pharmacological contributions beyond that of placebo reactivity. Prior to the more general use of the narcotic antagonists, the present authors participated in a long-term objective evaluation of a community-based abstinence program for addicts paroled from correctional institutions within the State of Maryland. This evaluation afforded extensive clinical experience with the opiate abuser in a program incorporating weekly group psychotherapy, a high level of parole supervision, and daily urine monitoring.” It was with such a baseline as a frame of reference that a series of studies was subsequently undertaken in the same setting to explore the efficacy of the administration of narcotic antagonists on a daily and “contingent” (upon evidence of narcotic drug use) basis. Superimposed on the already existing abstinence program, the narcotic antagonist research program extended over a six year period.7.x The first two studies of the program involved successive pilot and double-blind, controlled evaluations of the effectiveness of daily administered, low dose naloxone (Z~-800 mg), considered a partial or brief bIockade.g.‘v Two subsequent studies invoIved successive pilot and double-blind, controlled assessments of the effectiveness of higher dosage naloxone (500-2000 mg daily) administered on a contingent basis.*1,12A fifth study in the series was a double-blind, controlled evaluation of the comparative effectiveness of contingently administered, high dosage naloxone vs daily administered cyclazocine (up to 4 mg).‘” Regarding the typical reaction of the addict-parolee to narcotic antagonist medication, administered under both daily and contingent conditions, the results of our open and controlled studies to date have shown that the extent of nonspecific, or placebo, effects is quite remarkable. Convincingly demonstrating the superiority of a narcotic antagonist over its corresponding placebo under such conditions was, understandably, a more difficult task than we had first imagined. The mere taking of oral medication, even though inactive, apparently had a beneficial
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effect in terms of program retention and outcome. For example, in our controlled comparison of randomly assigned placebo and routine treatment (no medication) groups, both of which received parole supervision and group psychotherapy,“’ respective completion rates over a nine month treatment period were found to be 50% versus 259’0, indicating in this one instance. at least, a twofold advantage in favor of inactive oral medication. Even the addict’s knowledge that he will be administered an antagonist if he deviates appears to have a deterrent effect on narcotics use (which must be controlled for in evaluative research). In our program of research, six month outcome data on 108 addict-parolees participating in a contingent naloxone pilot study” revealed that 37% of the sample maintained complete abstinence and were, therefore, not administered antagonist medication. Previous results in the same setting with the nonchemotherapy sample of 371 abstinence program parolees having essentially the same prognostic characteristics had revealed only a 12% complete abstinence rate. Controlling for nonspecific reactivity, we were still able to identify two consistent responses to narcotic antagonists: a slight, though repeatedly discernible, decrease in narcotic drug use; and a consequent maneuvering to avoid medication, either intermittently or permanently. Although associated with less narcotic drug use, active medication showed no added benefit over placebo in terms of length of program participation or final disposition, which are generally considered the crucial criteria of effectiveness. Our findings have consistently suggested a relationship between avoidance, or refusal, of medication and the narcotic blocking capabiIity of the active agent. In our most recent report\“) on the contingent use of the antagonist naloxone with the addict--parolee, which we subtitled “The Failure of an Effective Approach,” we make the paradoxical point that effectiveness as an antagonist may preclude successful treatment outcome. Results of our double-blind, controlled study indicated that there was little reason to doubt that naloxone successfully blocked the euphoric and analgesic effects produced by opiates, thereby reducing the parolees’ incentive to use narcotics while medicated, Rather than inhibiting the drug-taking behavior of less motivated addict-parolees, however, the principal effect of naloxone appeared to be that of reinforcing avoidance of medication and indulgence in otherwise uncooperative behavior. It appears that motivation is a key determinant in the success of the antagonist approach with the addict-parofee. In the properly motivated parolee, the use of the approach can provide an important buffer to the process of readdiction. Although there are vital differences, in many respects the antagonist approach to the addict- parolee appears to be what Antabuse administration is to the alcoholic.” Just as Antabuse is now regarded as an adjunct to alcoholism treatment rather than the focus of therapy, the promise of antagonists appears to be principally in the adjunctive management of selected narcotic addicts who desire assistance in maintaining a state of abstinence so that supportive and psychotherapeutic resources can be utilized to advantage.
The conduct of our research over the years was not without the confrontation and, we hope, resolution of a number of emergent ethical and logistic issues.
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How, for example, can one guarantee the rights and welfare of an individual in an experimental situation involving both parole supervision and medical maintenance? Since a parolee’s rights are already severely restricted, is such an individual really free to discontinue treatment of his own accord, and if he does, what are the consequences? In our opinion, there is simply no debating the underlying issues here. No matter what his civil status may be, safeguarding the psychologic and physical integrity of an individual is an obligation in every research endeavor, even if doing so jeopardizes the research efforts or limits the generalization of results. Although he may be required to remain in a drug abuse treatment program of one kind or another, in a free society such as ours, a parolee, or any other individual for that matter, cannot be forced to take experimental medication against his will. Therefore, should he choose to discontinue such medication, he must be able to do so without prejudice to his parole status and without relinquishing any of his already limited rights. In comparative evaluations, research objectives are not entirely lost, however, if a parolee refuses to continue medication, since frequency and patterns of refusals may reveal differential information about the various treatments under study. Refusal to continue medication cannot only be utilized as a meaningful criterion of treatment effectiveness in itself, but can also provide a useful basis on which to categorize patients for follow-up evaluation purposes. For example, we have found that after they resumed narcotic drug use, parolees were more likely to refuse to continue experimental medication administered under double-blind conditions if they were receiving an active antagonist substance than if they were receiving placebo. And on follow-up evaluation, those parolees who had earlier refused medication were more likely to show evidences of general maladjustment and of narcotic drug use, in spite of continued involvement in the same abstinence program, than those who completed the prescribed medication schedule.12 There was another type of experimental subject attrition that we encountered that is unique to controlled studies of the narcotic antagonist approach. Unfortunately, not every subject chosen and treated in a narcotic antagonist program can be utilized in the evaluation process. Curiously, it is those who maintain complete abstinence through the medication period about whom we can say the least as far as treatment response is concerned. As paradoxic as it may sound, determining the effectiveness of a narcotic antagonist cannot be accomplished without narcotic drug use having occurred during treatment, It is not until the parolee-addict deviates that the impact of active medication can be measured and differentiated from the nonspecific (placebo) effects of taking a pill that allegedly blocks narcotic effects. The maintenance of complete abstinence on the part of the addict-parolee tells us little regarding the antagonist properties of a given agent in question and little to nothing about permanent extinction of drug-seeking behavior. Another logistic problem faced by antagonist researchers is common to all early drug evaluations. It is a well-known phenomenon that experimental procedures such as increased attention, more frequent patient contact, etc., have biasing effects on the measured outcome of an ~tervention, as dramatically illustrated by the often cited “Hawthorne effect.” In clinical research, artifactual effects are frequently positive ones, contributing to the attainment of improvement t’ates in excess of those ordinarily expected under routine conditions. That
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such effects are operative in narcotic antagonist research is obvious from our previous discussion. A less obvious experimentally induced artifact that precludes optimal effectiveness in early narcotic antagonist trials arises from the need for what under routine clinical conditions would be considered an jnordjnate amount of laboratory tests. Frequent and varied assays are admitt~Iy criticat during the preliminary stage of drug investigation since the purpose of early clinical trials is to obtain both drug dosage and human safety information. They do, however, represent a difficulty for the addict and undoubtedly contribute to lower treatment acceptability and more frequent dropouts, reactions that must be considered when evaluating the potential usefufness of newer narcotic antagonists subject to Phase IT experimentation, Neu! Directions One of the principal drawbacks to presently available narcotic antagonists is their short duration of action. Until the pharmacologic action of these agents can be suRcientty extended to minimize the addict-parolee’s capabibty of titrating his own medication intake, the value of the antagonist maintenance approach in any given case depends primarily on the consistency of the motivational level of the individual. For more general application, the biodegradable, sustained-release delivery system for a narcotic antagonist appears to hold special promise. Understandably, such complete control over another’s life by chemical means necessarily requires careful examination of important ethical issues reiating to individual freedom. More than ever, it would be imperative that treatment be entered into voluntarily only after self-acknowledged need and a verified awareness of available alternate treatments. Also, there should be full awareness of the restrictiveness and possible consequences of prolonged treatment effects. One obvious advantage of such precautionary measures woutd be that the less motivated parolee would more likely be identified prior to treatment rather than at an intermediate phase, thus saving both him and the treatment team subsequent frustration and disappointment. Granting a bewildering array of causative factors, compulsive narcotics use by addicts is at least partially attributable to diffuse ~sychophysioiog~ca~ discomfort, the alleviation of which is a signiticant reinforcer. TheSaiIureqffAezrorhPra~ellric intervention to deal direct/y with such discomjkt wii( irtevitabl_vresult in limited applicability and effectiveness. It is primarily for this reason that pure antagonists
do not seem to offer significant rehabilitative promise for the typical parolee or street addict. For many such individuals, there is simply no incentive or reward in the taking of a chemical that denies them the relief or comfort they obtain from narcotics. fn view of this, it seems advisable to supplement the search for pure narcotic antagonists with the search for antagonists with non- or minimally addicting agonistic properties, The combined use of an antagonist and a neuroleptic also appears to be an approach worthy of pursuit. Judiciously used during the early stages of parole, when stresses are maximal, the clinical use of new and/or combined agents might sustain the participation of less consistentty motivated addicts in therapeutic endeavors they might otherwise find tedious. As we have expressed elsewhere,’ innovative approaches to the treatment of the
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addict-parolee must be pursued to insure further progress in this area, One such approach is that of the combination of brief, drug-assisted psychotherapy with the narcotic antagonist model. A locally conducted series of controlled studies of drug-assisted psychotherapy employing lysergic acid d~ethylamide (LSD) and dipropyitryptamine (DPT)‘5-“’ suggested that rapidity of therapeutic impact may be one of the principal virtues of this intensive form of treatment, especially with addictive disorders. Apparently, within a matter of a few weeks persisting depression can be relieved, generalized anxiety and preoccupying distress reduced, and constructive motivation established. Another advantage is the apparent effectiveness of this type of therapy with culturally deprived patients who tend to score low on standard tests of intelligence and who would ordinarily be considered poor candidates for conventional therapy. Judging from our experience, the route to emotional reeducation represented by the method does not seem prejudiced against individuals lacking in verbal skills or sophistication. Additionally, other patients considered exceedingly difficult or inappropriate candidates for conventional treatment by virtue of their inability to enter into a therapeutic relationship (e.g. sociopathic and other personality disorders) can apparently be engaged by the brief, intensive procedures involved and continue meaningfully and effectively in therapy. Although found to be of demonstrated effectiveness with narcotic addicts,‘” drug-assisted psychotherapy is an essentially short-term, time-limited experience that cannot realistically be expected to sustain behavioral redirection and symptom control indefinitely. Narcotic antagonists, on the other hand, show promise in controlling narcotic drug use but do not alter root defects or conflicts in the personality system. Because the deficiency of each of these treatments is the particular strength of the other, it seems reasonable to postulate that a combination of the two might provide a new and effective treatment approach to the narcotic addict. SpecificaHy, brief, intensive psychotherapy, employing a short-acting agent such as DPT, followed by a maintenance course of the narcotic antagonist naltrexone2’ might be capable of effecting personality change and symptom control in those addict-parolees who seem refractory to all forms of therapeutic management short of sustaining their addiction with synthetic opiates. A PROPOSED
HIERARCHY
OF ADDICTION
TREATMENTS
Various approaches to the treatment of narcotic addiction, such as methadone and LAAM (I-alpha-acetylmethadol) maintenance programs, therapeutic communities, abstinence programs, and administration of narcotic antagonists, may be hierarchically conceptualized as offering increasing levels of difficulty for patient compliance and demanding successively greater degrees of patient motivation for satisfactory participation. 23 Methadone maintenance, for example, may be viewed as occupying the bottom position in the hierarchy of current treatments in that it allows the addict to continue daily narcotic consumption, thereby offering less difficulty for compliance and demanding relatively little motivation for continued program participation. (in this schema, LAAM maintenance would be considered as occupying a slightly higher position since longer-acting LAAM is less euphorigenic than methadone.) At the opposite extreme, an abstinence program represents a comparatively difficult approach for the addict (especially
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when applied with relatively few supportive services) and demands a high degree of motivation for successful participation. Since the attainment of complete abstinence in such a program is unlikely and since relapse to drug use is usually equated with program failure, the abstinence approach may be seen as occupying a position near the top of the hierarchy. Compared to these two extremes, a middle position seems appropriate for therapeutic communities, which typically demand abstinence of their residents but provide a fairly substantial degree of control and interpersonal support. As for the modality of more immediate interest, i.e., the administration of narcotic antagonists, indications as to where this fits into this conceptual framework and what may be expected from the use of these agents in terms of program retention and completion rates are currently emerging from early clinical studies and controlled research. Even though it is an alleged conditioning procedure involving the prescription ot medication, the narcotic antagonist approach is essentially another version of the abstinence approach, demanding the same patient characteristics for successful application. In view of the fact that the prescription of pure antagonists provides no directly pleasurable or ameliorative effect, the approach, as currently employed, earns a position near the top of the hierarchy. The unremarkable therapeutic results obtained in controlled evaluative research on the use of antagonists with unmotivated addicts is certainly not surprising. With such patients, there is little reason to expect the achievement of outcome results superior to any other abstinence program with the same underlying supportive services, including the administration of inactive medication. Since treatment modalities that demand abstinence are much more difficult for patient compiiance than those that do not (all other things being equal), abstinence programs cannot be expected to compete with maintenance approaches in retaining large groups of unselected addicts in treatment. Accordingly. the failure rates of the various types of treatment, from maintenance to abstinence. reflect the number of addicts who are “over their heads” in terms of the treatment hierarchy and who might do better in a lower level modality. Within the logic of this schema, it is inappropriate to ask if one treatment is better than another without considering patient readiness for treatment. It is not simply a question, for example of whether agonists are better than antagonists; one must ask the additional question: For what type of patient? Thus considered, one treatment is more suitable than another at different points along the continuum of treatment readiness. Should one treatment fail in a given case, another one lower in hierarchic order may be indicated. And following the same logic, should treatment at the lower end of the continuum be successful, the next step in the progression from opiate drug dependence to abstinence is the subsequent employment of a higher order treatment approach. Viewing the above information in the context of our present concern with the addict- parolee, it is our contention that most of these individuals are “over their heads” in the narcotic antagonist approach, and the fact that they do not do well in treatment tells us more about them than about treatment efficacy. Unfortunately, for the majority of addict--parolees, the administration of a narcotic antagonist is a treatment technique requiring more personal responsibility and motivation than such individuals possess at this point in their lives.
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ACKNOWLEDGMENTS The authors wish to express their appreciation to Friends Medical Science Research Center, Inc. for a~inistering the various projects involved in the narcotic antagonist program and to Dr. Albert A. Kurland, who initiated the overalt research effort. Most of the research cited was funded as part of NIDA Drug Abuse Center Grant DA-00415, the Principal Investigator of which was Dr. Charles Savage. The Maryland Drug Abuse Administration, Department of Health and Mental Hygiene, supported the underlying clinical program. Urine analyses were conducted by the Drug Abuse Laboratory, Friends Medical Science Research Center, Inc., under the direction of Dr. Robert Kokoski. In addition to the Narcotic Clinic Staff, under the direction of Ms. Bonnie Charyszyn, the help of the following individuals is gratefully acknowledged: Dr. Robert J. Blatchley, Ms. Hazel Bohmer, Mr. Steven F. Curran, Dr. Vasilios Frankos, Ms. Dorothy Sullivan, and Ms. Edwina Wilkinson. REFERENCES 1. Kimmel ME: Treatment of alcoholics in a correctional setting. Paper presented at the 23rd Annual Meeting of the Alcohol and Drug Problems Association of North America, Atlanta, Georgia, September, 1972 2. Nurco DN, Lerner M: Characteristics of drug abusers in a correctional system. J Drug Issues 2:49, 1972 3. McCabe OL, Kurland AA, Sullivan D: Paroled narcotic addicts in a verified abstinence program: Results of a 5-year study. Int J Addict 10:211, 1975 4. Marks PA, Sieman W: Actuarial Description of Abnormal Psychology. Baltimore, Williams & Wilkens, 1963 5. Gilberstadt H, Duker J: Handbook for Clinical and Actuarial MMPI Interpretation. Philadelphia, Saunders, 1965 6. Nurco DN, Farrell EV: Narcotic abusers and poverty. Criminology 13:389, 1975 7. Kurland AA, McCabe OL, Hanlon TE: Contingent naloxone (N-allylnoroxymorphone) treatment of the paroled narcotic addict. Int Pharmacopsychiatry 10: 157, 1975 8. Hanlon TE, Kurland AA, McCabe OL: Naloxone treatment of the paroled narcotic addict: A program of research, in Singh S (ed): Drug Addiction: Neurotherapy and Other Treatments, vol5, 1977 (in press) 9. Kurland AA, Krantz JC, Henderson JM et al: Naloxone and the narcotic abuser. A low dose maintenance program. Int J Addict 8: 127, 1973 10. Kurland AA, Hanlon TE, McCabe OL: Naloxone and the narcotic abuser: A controlled study of partial blockade. Int J Addict 9:663, 1974 1I. Kurland AA, McCabe OL, Hanlon TE: Contingent naloxone treatment of the narcotic addict: A pilot study. Int J Addict I 1:13I, 1976 12. Hanlon TE, McCabe OL, Savage C et al: Narcotic antagonist treatment of ad-
diet-parolees-The failure of an effective approach. Compr Psychiatry 18% l-220,1977 13. Hanlon TE, McCabe OL, Savage C, et al: A controlled comparison of cyclazocine and naloxone treatment of the paroled narcotic addict. Int Pharmacopsychiatr l&240, 1975 14. Doherty J: Disulfiram (Antabuse): Chemical commitment to abstinence. Alco Health Res World, Spring, 1976 15. Pahnke WN, Kurland AA, Unger S, et al: The experimental use of psychedelic (LSD) psychotherapy. JAMA 212:1856, 1970 16. Kurland AA, Savage C, Pahnke WN, et al: LSD in the treatment of alcoholics. Pharmakopsychiatr Neuropsychopharmakol 4:83, 1971 17. Savage C, McCabe OL, Kurland AA, et al: LSD-assisted psychotherapy in the treatment of severe chronic neurosis. J Altered States Consciousness 1:31, 1973 18. Savage C, McCabe OL: Psychedelic therapy of drug addiction, in Brown C, Savage C (eds): Drug Abuse Controversy. National Educational Consultants, Baltimore, 1972 19. Savage C, McCabe OL: Residential psychedelic (LSD) therapy for the narcotic addict. A controlled study. Arch Gen Psychiatry 28:808,1973 20. Grof S, Soskin RA, Richards WA, et al: DPT as an adjunct in psychotherapy of alcoholics. Int Pharmacopsychiatry 8:104, 1973 21. Soskin RA, Grof S, Richards WA: Low doses of dipropyltryptamine in psychotherapy. Arch Gen Psychiatry 28:817, 1973 22. Martin WR, Jasinski DR, Mansky DA: Naltrexone, an antagonist for the treatment of heroin dependence. Arch Gen Psychiatry 28:784, 1973 23. McCabe OL: Heroin maintenance: An assessment of its potential role in the rehabilitation of chronic heroin abusers. Drug Forum 4:95, 1975
