OVERVIEW OF TREATMENT APPROACHES FOR OPIATE ADDICTION: A SCOTTISH PERSPECTIVESubstance use disorders are some of the most widespread mental and behaviouraldisorders affecting individuals on a global scale. Substance dependence is characterisedby compulsive and uncontrollable use of a substance and is associated with physiologicalwithdrawal symptoms with the sole pursuit of substance use despite the occurrence ofserious harm to self or others (Abou-Saleh, 2006). Opiate derivatives such as heroin havebeen recognised as some of the most addictive and problematic substances in the worldtoday with the total number of opiate users at a global level now estimated atapproximately 16.5 million people with the annual prevalence rate of 0.4% of thepopulation aged 15-64 having remained stable since the 1990’s (United NationsDepartment Of Drugs and Crime 2008). Europe remains the second largest consumermarket for opiates with the United Kingdom being one of the major opiate markets inWestern Europe with and estimated number of 340,000 people consuming these drugs(United Nations DODC, 2008). Scotland in particular has a significant number ofproblem users with an estimated 52,000 people experiencing drug dependence, a numberthat is notably higher than for England as well as other similar European countries suchas Ireland, Finland or Denmark (Scottish Executive 2008). Research based on theoutcomes of the Drug Outcomes Research in Scotland study (DORIS) indicates thatproblem drug use in Scotland has been recognised as having a significant impact onmortality rates in comparison to the rest of the UK (Bloor, Gannon, Hay, Jackson,Leyland & McKaganey, 2008). The impact of problem drug use on the individual andsociety as a whole is profound with injecting drug use being associated with a high riskfor contracting blood-borne infections including HIV, hepatitis C and Hepatitis B (Abou-Saleh, 2006). Recent figures for Scotland demonstrated that 85% of Hepatitis C suffererscontracted the disease from sharing injecting equipment and other paraphernalia (ScottishExecutive 2008). Problematic heroin use is also associated with deterioration in self-esteem and social relationships (Wermuth, Brummett & Sorensen, 1987) and has alsobeen found to have enormous social costs due to crime and unemployment (Amato,Davoli, Perucci, Ferri, Faggiano & Mattick, 2005; Scottish Executive, 2008). It is clearthat problematic drug use, and in particular addiction to opiate derivatives such as heroinhas had a significant impact over the past 20 years and as a result a great deal of researchhas been carried out as to the most effective methods of treatment and care forindividuals affected by this issue.The most widely available treatment intervention for opiate dependence is the use ofpharmacotherapy which aims to alleviate craving and withdrawal symptoms associatedwith illicit opiates, or facilitate detoxification from illicit opiates. This is achieved byadministering stable or tapered doses of medications to the heroin user. This can beachieved by substituting illicit opiates for clinician prescribed opiate-based medications.The two most widely prescribed medications for this are methadone and buprenorphine(Lingford-Hughes, Welch & Nut, 2004). The primary aim of such interventions is toallow opiate dependent individuals to regain a greater degree of control over their heroinuse which in turn will lead to a reduction in time spent on drug related activities with the
future aim of entering into detoxification, and eventually achieving an opiate free life(Ward, Hall & Mattick, 1997). In the United Kingdom, the standard substitute drug ofchoice is methadone (Matheson, Bond, & Hickey, 1999; Wilson, Watson & Ralston,1994; Best, Gossop, Marsden, Farrell & Strang, 1997). Recent figures for Scotlandindicated that the number of prescriptions for methadone mixture was estimated at457,092 and that methadone prescribing rates have risen by 45% over the last five years,from 62 per 1,000 population in 2001/02 to 90 per 1,000 population in 2005/06(statistical publication notice, Information Services Division NHS 2006).Methadone substitute treatments have consistently provided evidence demonstrating asustained reduction in illicit drug use among heroin users (Dole et al., 1969; Gunne &Gronbladh, 1981; Newman & Whitehill, 1979; Simpson, Joe, Dansereau, & Chatham,1997; Ward et al 1997; Yancovitz et al., 1991). Methadone-based treatment programmeshave also demonstrated increases in the time between frequency, intensity and length ofheroin use relapse (Leshner, 1998), as well as reductions in overdose risk, criminalactivity and exposure to blood-borne viruses (Farrell et al., 1994; Leshner, 1998; Ward etal., 1999). Detoxification from opiates can also be achieved using tapered doses ofmethadone or buprenorphine, or using α-adrenergic medications such as clonidine orlofexadine to suppress withdrawal symptoms (Lingford-Hughes et al., 2004).However, despite its effectiveness in reducing dependency on illicit opiates such asheroin, methadone substitution therapies have not been without criticism. The initialstages following the introduction of methadone maintenance programmes in Glasgow in1994 resulted in a substantial increase in drug-related deaths as a result of a lack ofconsistency and regulation of prescriptions and dispensing (Seymour, Black, Jay, Cooper,Weir & Oliver, 2003). An early review of methadone based substitution treatmentshighlighted a number of problematic factors associated with methadone including, theaddictive nature of methadone itself and the need for gradual detoxification to effectivelyachieve opiate-free status (White, 1994). This review also indicated that methadone canalso increase the toxicity of other drugs including benzodiazapines and alcohol due to itsdepressive effect on the central nervous system (White, 1994). Recent research carriedout by the Scottish Drugs Forum as part of the Scottish Executive’s review of methadonebased treatment interventions highlighted that although such treatments were effective inachieving a degree of stability in the lives of service users, it was highlighted that manyservice users and their carers viewed methadone as simply replacing one drug withanother and that such treatment programmes were aimed at crime reduction rather thanfacilitating positive long-lasting change for the service user (Scottish Drugs Forum 2006).Other difficulties highlighted included the lack of consistency in service delivery andprovision as well as a lack of service user involvement in care planning and a distinctlack of support with regards to the underlying psychological and social factors associatedwith their drug use (SDF, 2006). Further research has also indicated that the stigmaassociated with drug treatment services themselves can be a significant reason fordisengagement (Copeland, 1997). Radcliffe & Stevens (2008) highlighted that for someheroin users, the treatment regime itself could be stigmatising due to segregation inpharmacies and supervised consumption. It was also evident that methadone maintenanceprescriptions marked out recipients as separate from and outside ‘normal’ life
encompassing difficulties with maintaining employment and for travel within and outsidethe UK (Radcliffe & Stevens, 2008). Early research has also highlighted the vulnerabilityof individuals moving towards a gradual decrease in methadone substitution treatmentdue to a lack of adequate support and structured aftercare to ensure abstinence andprevent relapse (Wermuth, Brummet & Sorensen, 1987).As well as pharmacological interventions, the self-help movement has led to a vastincrease in 12-step programmes aimed at promoting recovery and maintaining abstinencefrom addictive substances (Peteet, 1993; Fenster, 2006; Vederhus & Kristensen, 2006).The popularity of such approaches began with the establishment of AlcoholicsAnonymous in 1935 (AA, 2008) with Narcotics Anonymous appearing 20 years later(NA, 2008). The philosophies of groups such as NA are based on a group of principlesthat are intended to be practiced as a way of life (NA, 2008). These include the admissionof a problem; the searching for help; thorough self examination; practicing amends forharms done to others; and ultimately helping other drug addicts to recover and achieve apromised ‘spiritual awakening’ (NA, 2008). The focus of this approach is the diseasemodel of addiction whereby substance dependent individuals are thought to suffer from achronic disease that is out with their control and that recovery can only be achievedthrough lifelong abstinence (NA, 2008; King, Bissell & O’Brien, 1979, Peteet, 1993).Limited research in this field has highlighted the apparent efficacy of 12-stepprogrammes as a treatment approach in the reduction of drug use and maintainedabstinence (Connors, Tonigan & Miller, 2001; Moos & Moos, 2004; Hoffmann, Harrison& Belille, 1983). Twelve-step programmes have also demonstrated positive change byenabling service users to establish new social networks (Kaskutas, Bond & Humphreys,2002), and to achieve increased self-esteem and a subjective improvement in social status(Zemore, Kaskutas & Ammon, 2004). Research by Peteet (1993) also suggested that 12-step programmes provide accessible group support and address individuals’ needs foridentity, integrity and interdependence within a larger social, moral or spiritual context.The potential cost-effectiveness of such programmes has also been highlighted althoughfurther research in this area is necessary to determine the overall benefits (Kelly,2003).However, despite the growing body of research concerning the positive benefits of 12-step programmes and their considerable distribution in the United States, the situation inthe UK is very different with most National Health Service (NHS) statutory servicesdemonstrating considerably less utilisation of 12-step ideology (Day, Gaston, Furlong,Murali & Copello, 2005). This has been attributed to a degree of cynicism towards suchprogrammes within both substance using and professional cultures (Wells, 2005). Areview of the research regarding the effectiveness of 12-step programmes indicated thatalthough there was a growing body of empirical evidence for the efficacy of AA as atreatment approach for those with alcohol dependence, little is known about the specificeffectiveness of other self-help groups focused primarily on other substances such as NA(Kelly, 2003). High drop-out rates have also been demonstrated with regards to 12-stepprogrammes with some research demonstrating up to 50% drop-out rates within the 90-day introductory period (Humphreys, Huebsch, Finney & Moos, 1999; McIntire, 2000).Earlier research by Peteet (1993) highlighted some of the criticisms that have beenassociated with 12-step programmes including their inability to address and facilitateunderstanding of the dynamic roots of addictive behaviour as well as their focus on
interdependence rather than independence, and encouragement of powerlessness and alack of responsibility for one’s behaviour and recovery. Another continuing issue withregards to 12-step programmes is their strong religious overtones, which may serve as abarrier to service user utilisation (Peteet, 1993). Other barriers that have been noted withregards to 12-step programmes include some members’ negative view towardsindividuals taking psychotropic medication in conjunction with their affiliation with thesegroups (Kelly, 2003; Rychtarick, Connors, Dermen & Stasiewicz, 2000). It has also beensuggested that opiate dependent patients who are using methadone treatment view the 12-step principle of total abstinence from all narcotic use as a significant barrier to accessingprogrammes such as NA (Kelly, 2003).The field of psychological research has seen the development of a number of theorieswith regards to addictive behaviour which has served to generate several treatmentapproaches to address this issue (Wanigaratne, 2006). Social Learning Theory as firstintroduced by Bandura (1977) served to introduce the concept of cognitive processes inlearning. Cognitive factors such as anticipation, planning, attributions, self-efficacy anddecision making were all shown to be significant in learning (Wanigaratne, 2006).Marlatt & Gordon (1985) proposed the cognitive-behavioural model of the relapseprocess and the subsequent treatment approach that has been developed as a result of thishas had a significant impact in the treatment field (Wanigaratne, 2006). Interventionsbased on this model contain elements which serve to increase the service user’sawareness of the relapse process in general as well as their own individual pattern inrelation to this (Wanigaratne, 2006). Such approaches examine the patterns ofindividuals’ previous relapse experiences and increase insight by identifying individualstrengths and weaknesses and involve skills training to work towards establishingpositive coping strategies (Wanigaratne, 2006). Relapse prevention strategies havedemonstrated promising treatment outcomes in the field of substance misuse (Rawson,Obert, McCann & Marinelli-Casey, 1993). Research examining the efficacy of anintensive outpatient treatment model for opioid users which incorporated relapseprevention principles in combination with self-help concepts indicated positive treatmentoutcomes (McAuliffe, 1990; McAuliffe & Ch’ien, 1986). Positive outcomes includedsuperior levels of opioid abstinence at 6 and 12 months follow-up as well as significantlymore employment activity and less criminal activity in comparison to the control group(McAuliffe, 1990). Other relapse prevention programmes such as Self Management andRecovery Training (SMART) have combined priniciples of Rational Emotive BehaviourTherapy (Ellis, 1988) and cognitive techniques to secure abstinence and promote selfawareness and positive coping techniques (Fenster, 2006). Although some researchexamining the treatment outcomes of programmes such as SMART have demonstratedsignificant results (Brooks & Penn, 2003), there is still a significant lack of empiricalresearch examining the efficacy of such treatments (Kelly, 2003).Other psychological theories that have emerged with regards to addiction includePsychodynamic approaches which suggest that substance dependence is closely linkedwith pre-existing underlying psychopathology and an inability to cope with resultingpainful emotions (Wurmser, 1973) as well as being strongly associated with pasttraumatic experiences (Hopper, 1995). Khantzian (1977) introduced the concept of self-medication as a motivation for substance misuse. This in turn has had considerable
influence in the field of comorbid substance misuse and mental illness (Wanigaratne,2006). Treatment approaches based on these principles have involved helping theindividual to achieve abstinence through the therapeutic relationship with a drugs worker(Wanigaratne, 2006). However, although counselling based on psychodynamicprinciples became the main intervention in various treatment settings, it was oftencarried out by individuals with little or no knowledge of underlying psychodynamicprocesses (Wanigaratne, 2006). It is suggested that this lack of clear framework intreatment settings is related to limited treatment outcomes using this approach(Wanigaratne, 2006).One of the most influential psychological models in the field of addiction has been theStages of Change model originally developed by Prochaska & DiClemente (1996). Thecentral concept of the model is motivation and its considerable role in explaining whyand how people change addictive and health behaviours (DiClemente, Nidecker &Bellack, 2006). The model suggests that behaviour change takes place in discreet stages:the pre-contemplation stage; the contemplation stage; the decision stage; and themaintenance stage in which successful change in behaviour is achieved (Prochaska &DiClemente, 1996). A key treatment approach that has been developed as a result of thismodel is Motivational Interviewing (Miller & Rollnick, 1986). Motivationalinterviewing can be thought of as a client-centred counselling style incorporating non-judgemental, empathetic and non-confrontational principles to facilitate a supportiveenvironment in which clients can explore both positive and negative aspects of theirbehaviour (Miller & Rollnick, 1991). The main aim of Motivation Interviewing is toassist service users to work through their ambivalence about behaviour change and it hasbeen found to be effective for those who are in the beginning stages of readiness forchange (Miller & Rollnick, 1991; Resnicow, Dilorio, Soet, Borrelli, Hecht & Ernst,2002). Motivational enhancement techniques have been found to produce improvedoutcomes in a range of substance misuse patients (Miller & Rollnick, 2002; Stotts,Schmitz, Rhoades & Grabowski, 2001). Such approaches have also been shown toimprove treatment engagement and retention in individuals with comorbid substancemisuse and mental health issues (Swanson, Pantalon & Cohen, 1999; Daley, Salloum,Zuckoff, Kirisee & Thase, 1998).Psychosocial interventions are continuing to gain greater status in treatment approachesto addiction and the growing body of evidence based practice has highlighted that futuredirections should involve the integration of different psychological approaches in order tomake available a range of targeted treatments to substance dependent individuals atdifferent stages of the recovery process (Wanigaratne, 2006; Wanigaratne & Keaney,2002) which in turn could serve to enhance positive treatment outcomes, particularly forthose with comorbid substance use and psychiatric disorders (DiClemente et al. 2006;Mueser, Noordsy, Drake & Fox, 2003). Clinicians and service providers have long beenaware that service users with substance use issues frequently presented with psychiatricconditions in conjunction with, preceding or following on from the substance usedisorder itself (Glass & Jackson, 1988). The World Health Organisation (WHO) and theUnited Nations Office on Drugs and Crime (UNODC) define dual diagnosis as “a persondiagnosed as having an alcohol or drug abuse problem in addition to some other
diagnosis, usually psychiatric such as mood disorder or schizophrenia”, while theEuropean Monitoring Centre in Drug Dependence and Alcohol (2004) make reference toco-morbidity or dual diagnosis as being the co-existence of two or more psychiatric orpersonality disorders as defined by the International Classification Diagnostic System(WHO, ICD-10 1993).The relationship that exists in co-morbidity is complex and can present in many differentways (Crome, 1999). Symptoms of psychiatric or psychological disorders may resultfrom substance use, dependence, intoxication or withdrawal. Moreover, psychiatricdisorders may lead to or precipitate substance misuse, which in turn can lead topsychiatric syndromes (Baldacchino, A., 2007).Various early studies have demonstrated the prevalence of co-occurring mental disordersand substance use disorders (Robins & Regier, 1991). The 1990 EpidemiologicalCatchment Area (ECA) study in the United States was one of the first population surveysconducted that demonstrated 29% of people presenting with a mental disorder had alsoexperienced a substance use disorder. Conversely, they found that 64% of people beingtreated for drug disorders had at least one co-morbid mental illness (Regier, Farmer, Raeet al., 1990). Further research carried out by the National Co-morbidity Study (NCS) in1994 found that 48% of people surveyed reported a substance misuse disorder orpsychiatric illness in their lifetime (Kessler, McGonagle, Khaao, et al.1994). Studiesinvolving individuals whose primary disorder was substance use indicated that the mostprevalent co-morbid mental disorders were anxiety disorders, affective disorders,antisocial personality disorders and schizophrenia (Regier et al., 1990). Borderlinepersonality disorder is also strongly associated with problematic drug use (AmericanPsychiatric Association 2000; Trull, Sher, Minks-Brown, Durbin & Burr, R., 2000).A report released by the Scottish Executive in 2003 (Mind the Gaps: Meeting the Needsof People with Co-occurring Substance Misuse and Mental Health Problems ) isdescribed as compendium of evidence-based Scottish research highlighting theprevalence and treatment recommendations for those with co-morbid substance use andmental health issues (Scottish Advisory Committee on Alcohol/Drug Misuse 2002). Theevidence compiled highlighted that 3 out of 4 drug using clients engaging with serviceswere reported as having mental health problems, and that an estimated 2 in 5 peoplepresenting primarily with mental health problems also had a drug and/or alcohol problem,( Scottish Executive 2003). Evidence from the Scottish drug Misuse Database (SDMD)showed that for the period of April 2001 to March 2002 over 40% of people who soughttreatment reported that their mental health was one of the main issues which led them toseek treatment (Scottish Executive 2003). Further research gathered for the report alsoindicated that in a nationally representative sample of Scottish general medical practices35.2% of consultations with drug misusing patients were for either mood or anxietyrelated disorders (Scottish Executive 2003).The presence of co-morbid psychiatric conditions and the severity of psychosocialproblems have been related to poorer treatment outcomes across a variety of studies(McNulty, J., Kouimtsidis, C., 2001). Research has highlighted difficulties with non-
adherence with medications, symptom exacerbation, re-hospitalisation, poor socialadjustment, an overall lack of therapeutic engagement and relapse after initial successfulchange in dually diagnosed individuals ( Blanchard, 2000; McGovern, Wrisley, & Drake,2005; Mueser, Drake, Turner, & McGovern, 2006).There are a wide range of pharmacological treatments used for the purposes of attracting,engaging and retaining service users, and to enhance motivation to seek further supportfrom specific psychological treatments in relapse prevention (Baldacchinno, 2007)Furthermore, there are increasing numbers of guidelines being established for thetreatment of substance misuse and/or mental illness (Hole, 2005; Ludbrook, Bird & vanTeijlingen, 2005; Department of Health - Drug Misuse and Dependence, 1999; EffectiveInterventions Unit, 2002). However, research carried out by Mental Health Foundation,supported by Turning Point Scotland, in 2003 found that the views of many service usershighlighted significant problems in service provision. Views expressed by service usersincluded feeling that services only focused on one problem rather than the range ofproblems they faced, and the fact that many felt that had been prevented from accessingmental health services until their substance misuse issues had been addressed first. Theview that accessibility was difficult due to long waiting lists and inflexible appointmenttimes being offered were also expressed (MHF, 2003). Other research in this area hasalso indicated that there is a tendency for services to separate general psychiatric andsubstance misuse issues. The result is that some people can fall through the cracks(Aboul-Saleh, 2004).Research in the field of co-morbidity has highlighted some potential approaches that maylead to positive outcomes in this population. An early study by Franco et al. (1995)indicated that peer led token economies base on behavioural principals were associatedwith a decrease in negative behaviours and an increase in patient participation in groupactivities. Further research also provided some evidence for contingency managementconsisting of both incentives and disincentives to prevent continued illicit drug use andthere by providing positive outcomes (Griffith, Rowan-Szal, Rowark, & Simpson, 2000).Swanson, Pantalon & Cohen (1999) indicated that motivational techniques based onmotivational interview principles were associated with increased patient treatmentretention in dually diagnosed patients. Further research found that motivationalinterventions increased attendance and treatment engagement and decreasedhospitalisations in patients with co morbid depressive disorders and substance misuse.There is also growing support and consensus for the combination of approaches such ascognitive behavioural and motivational interviewing, and the need for integration oftreatments for those with co-morbid psychiatric and substance misuse disorders (Mueser,et al., 2003; DiClemente, et al., 2008). Although there is some evidence for theeffectiveness of certain psychological interventions, there is still a distinct lack ofempirical research providing clear indications as to what works in the field of co-morbidity (Baldachinno, 2007). The Scottish Model for co-morbidity is based upon 5 keysteps. These include community and social support, generic services, generic service withsome specialised function, such as the community mental health team within mentalhealth services, and the community drug and alcohol teams. Other steps within the modelinclude specialist services such as the co-morbidity led nursing services in rural areas and
multi disciplinary assertive outreach teams. The final step involves highly specialisedtreatment resources such as regional co-morbidity units (Scottish Executive 2002).Despite these recommendations it has been highlighted that problems with and gaps inservice provisions still persist. The co-morbid mental health and substance misuse inScotland study (Hodges, Taikato, McGarrol, Crome & Baldecchino 2006). Results of thisstudy indicated that both service providers and service users identified a number ofdeficits in service provision. These included difficulties in accessing services; lack ofcrisis support; lack of continuity of care; lack of access to psychological therapies;overemphasis on medication based treatments; lack of service user involvement in careplanning; a lack of specialist services addressing antecedent issues such childhood trauma(Hodges et al., 2006).It is clear that there are a number of treatment interventions for opiate dependence. Todate, it would appear that substitutive and maintenance treatments with Methadone arethe most widely researched and implemented in Scotland. It is also evident that addictionand substance use are complex disorders and involve the interaction of various biological,psychological, psychiatric and social factors. This further highlights that there is a needfor greater variety of treatment interventions to be made available at different timesthroughout the course of recovery from substance dependence. This is especially truegiven the growing awareness of the prevalence of co-morbidity of mental health andsubstance use disorders, and their chronic relapsing nature requiring focused and flexibleresponses at different levels and tiers within health and social care. Clinical servicesshould view co-morbidity as the norm rather than the exception and should thereforeadopt a holistic and inclusive approach. Effective and integrated interagency andmultidisciplinary partnership working, more thorough shared assessment and service userneeds identification, and individually tailored care plans involving service users shouldbe the future direction. This would facilitate the development of services which are needsled rather than service led.
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