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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

What’s Missing?

Ray Baker, MD

Reprinted from "Criminal Justice" issue of Visions Journal, 2005, 2 (8), p. 8-10

Treatment of addiction

Substance dependence is recognized as a medical, psychiatric and psychosocial disorder. People with substance dependence are entitled to protection from discrimination and should qualify for quality, evidence ­based treatment. Unfortunately, substance dependent people often receive second ­rate care that would not be tolerated with other illnesses.

A large and growing body of research evidence shows the effectiveness of certain types of treatment for substance dependence. As with other complex medical disorders with biological, psychological, social and spiritual components, treatments combining different modalities of therapy have better outcomes. Cognitive therapy (identifying and correcting negative ways of thinking), motivational enhancement therapy (using techniques that convince clients to change their behaviour), and mutual support group facilitation have all shown impressive effectiveness. Outcome studies following residential treatment have shown that the initial improvement in health and function seen at completion of the inpatient program can be maintained with higher rates of prolonged success through mutual support group involvement and individual or group psychotherapy.

Effective pharmacological interventions include methadone or buprenorphine for people with intravenous heroin or morphine dependence, bupropion and nicotine replacement for nicotine dependence, and acamprosate and naltrexone for some people with alcohol dependence. Pharmacological treatments for substance dependence are much more effective when combined with psychosocial and behavioural interventions and support.

People with psychiatric comorbidity (mental illness as well as addiction) have much better results when their psychiatric condition is treated at the same time they receive addiction treatment.

Contingency management

Contingency management refers to rewarding a person for participating in treatment and allowing certain natural negative consequences to occur if someone chooses not to follow their recovery plan. Disability health insurers do this when they withhold benefits from a person who is off work with an addictive disorder, but who is unwilling to get help. Employers do this with safety ­sensitive employees suffering from addictive disorders: return to work is contingent upon the worker adhering to an abstinence ­based treatment and a relapse prevention program. This approach has also proven effective in drinking driver diversion programs, in drug courts and in programs used for rehabilitation of substance dependent pilots and health professionals. If a substance dependent pilot or physician chooses to continue to use addictive drugs, they are not permitted to function in an occupational setting that could cause harm to others.

Is harm reduction a good thing?

Harm reduction refers to offering treatment to substance dependent patients without insisting they be abstinent as a condition of treatment. Certain types of harm reduction, when carefully administered, are effective in decreasing the number of deaths and the substance ­related health consequences while improving function and quality of life in substance dependent populations. Safe injection sites, for example, have shown promise, especially when they are structured as a portal to engage drug users with a comprehensive network of treatment services.

If poorly done, however, well­ intended harm reduction programs can cause harm. It is important to recognize enabling: that is, sheltering a competent person from the consequences of their repeated behaviours. Substance dependent people continue to use mood altering drugs because they are effective: the benefits of drug use seem to outweigh the costs or consequences. In order to get help, the dependent person needs to “hit bottom” (i.e., become convinced, at least for a little while, that the cost of their substance use outweighs its benefits.) The sheltered, drug dependent person may never come to this realization.

Despite research trials in three countries, the evidence supporting heroin substitution as a cost ­effective harm reduction therapy is unconvincing. And, interestingly, countries such as Switzerland, which has demonstrated remarkable success using harm reduction to minimize street drug activities, always have a robust police enforcement component reminding the addict of the consequences of their behaviour choices.

What is the current status in BC?

As a long ­time addiction medicine clinician, it appears to me that British Columbia (and Canada) has decided on an ideological approach that represents a cynical, negative way of thinking: “The war on drugs has hurt more than helped.” “Our way of doing it has not worked.” “The problem is the law; if we make drug use legal we will solve many of the current problems.” But, we must be careful not to throw the baby out with the bathwater.

Intervention approaches that stress harm reduction components (needle exchanges, injection sites, addictive drug distribution) at the expense of adequate, evidence­based treatment (drug­free housing, therapeutic communities/support recovery houses, inpatient detox, residential and outpatient treatment programs) represent an ideological shift rather than a rational and balanced approach using scientific evidence to deal with a complex issue.

what is addiction?

The term substance dependence (alcoholism, drug addiction) is used to describe a continuum of conditions that are considered diseases or disabilities by both legal and medical authorities.

Increased risk for addictions may be inherited, but, as with many other illnesses, it may be acquired due to other risk factors such as early or heavy use of addictive substances, sustained emotional discomfort, a history of emotional trauma, or concurrent psychiatric disorders.

The abnormality within the brain that characterizes drug dependence is believed to result from a relative under-functioning of the circuitry responsible for reward, pleasure and the ability to maintain a balanced mood. This results in a person with substance dependence being unable to soothe or comfort themselves during times of emotional distress. The affected person receives powerful reward or reinforcement when they use addictive substances (or engage in other behaviours associated with a risk for addiction, such as gambling) known to activate these “pleasure centres” of the brain.

With continued excessive drug use, further changes occur in the structure and function of parts of the brain. These changes are believed to be only partly reversible. For this reason, addictions are viewed as chronic disorders, and treatment should be followed by long-term relapse prevention.

Almost a decade ago Vancouver instituted a four pillar approach,1 based on the four pillars program (prevention, enforcement, treatment, harm reduction) initiated in Switzerland. In transplanting the Swiss program, however, they seem to have neglected some of the pillars (enforcement, prevention, treatment) and supported others (needle exchanges, safe injection sites, methadone maintenance, heroin substitution). BC already had one of the largest needle exchanges in North America during the late 1980s, well before experiencing the Western world’s highest rate of HIV infection during the early ’90s. With safe injection sites in place and a small heroin substitution program operating, deaths from illicit drug use are still alarmingly common. The open drug scene in Vancouver and other BC cities is thriving, even growing. There is an epidemic of property crime, widely acknowledged to be due to the drug problem. Illicit drug production is thought to be BC’s second leading industry.

Illicit drug production is thought to be BC's second leading industry

In terms of treatment, we still lack adequate drug free safe housing, residential treatment resources such as therapeutic communities, or support recovery houses where substance dependent people can stabilize while receiving outpatient services. We lack intensive residential treatment centres capable of safely treating a substance dependent person with concurrent psychiatric or medical illness.

If addiction is considered a bona fide health disorder, we could be accused of violating the Canada Health Act by failing to provide adequate treatment for people with addictions and by permitting barriers to treatment, such as user fees for residential treatment and methadone maintenance programs.

Additionally, we lack adequate integrated care for people with psychiatric disorders complicated by addictions. In most Canadian medical schools, post­graduate counselling psychology programs, schools of social work, and nursing education programs there is no systematic addictions curricula.

We are missing an opportunity within the criminal justice and corrections systems to provide therapeutic interventions. Greater than 50% of incarcerated youth and adults suffer from substance use disorders. Treatment is actually less expensive than incarceration. There is also good evidence from many studies showing that not only is treatment effective, but that treatment of substance use disorders results in economic benefits for society (e.g., reduction of crime, decreased health costs, increased employment).1 Although some corrections facilities offer treatment to inmates, many do not. Some of the money spent incarcerating offenders, whose crimes were related to drugs, could be used for effective, contingency ­based treatment programs.

There is a great deal of evidence on approaches that work, but we have not rigorously applied them. Perhaps it is time we did.

 
About the Author

Dr. Baker is Medical Director of Health Quest Occupational Health Corp. and Assistant Clinical Professor in the UBC Faculty of Medicine. He specializes in addiction medicine and provides consultation on addictions and mental health. He also designed and directed Addiction Medicine and Inter-collegial Responsibility (AMIR), an award-winning UBC undergraduate program

Footnotes
  1. MacPherson, D. & Rowley, M. (2001). A framework for action: A four-pillar approach to drug problems in Vancouver. Vancouver, BC: City of Vancouver.

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