Which type of treatment works best in treating those with substance use problems?

Posted: January 13, 2014 in Uncategorized
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To discuss  “Which type of treatment works best in treating those with substance use problems?” we first have to examine what is meant by treatment, and then look at what is currently used, and evaluate what if any of the techniques “work best”.

 Treatment within substance use, can be broadly split into two distinct phases, intervention, and  recovery maintenance. Intervention being the initial phase utilising assessment, intervention delivery and continuity planning including relapse  prevention/management, and  recovery maintenance encompasses the  process of recovery itself, relapse and if needed condition management if mental/physical health issues are identified.

 Intervention:

 Intervention for substance use issues are varied, and range from pharmacological Interventions for substance use related issues,(Barbor et al 2010) such as Methadone Replacement Therapy and Buprenorphine for opiate use to Disulafram and Campral for dependant alcohol use, to Cognitive Behavioural based interventions e.g. Health Behaviour Change and Motivational interviewing, and most often  both forms of intervention are utilised together initially (Rollnick et al 1999). The majority of these  are delivered within a “medical model” requiring assessment, and then some form of prescribed treatment plan which is controlled by the prescribing  or referring medical practitioner which has been described as social control (Naidoo & Wills 2000, Berridge 1999, Peele 1998). The underlying concept within this process is that of abstinence being the ultimate goal for treatment, reflecting back to the “Treatment works” statements from the treatment effectiveness review from the 1990’s (Berridge 2012). These interventions are all time limited, by the clients interaction with the treatment agency, traditionally only focusing on the short term contingency planning provided by practitioner who engaged with the client, which focused on problem solving, and basic cognitive behavioural work and possibly pharmacological input to prevent drinking (disulafram,) or block cravings (Accamposate).Once the engagement time came to an end the client was referred back to his or her GP, with contact information for mutual aid societies.The service would then “discharge” the client, and encourage them to utilise third sector, or 12 step recovery support networks..

Recovery Maintenance

Recovery, and it’s associated theories of personal development can be traced back to the idealology of the temperance movement, and the idea of the “inebriate” being controlled by the disease of Alcoholism, and that abstinence is the only cure.(Berridge 2012). The current concept can be directly traced to the Mental Health Recovery movement and Models such as the “Tidal Model”  (Barker 2005), and the government paper “Road to Recovery” (Scottish Government 2008) which looks at building capacity and helping service users move on from addiction, through personal development supporting the development of relapse prevention skills encouraging abstinence, and providing more of the long term support and behaviour change through Cognitive Behavioural based work, and group therapies. .
With the general acceptance of this concept, and the indication of government  acceptance of the concept as a way to deal with substance use(Scottish Government 2008) there has been growth in the third sector especially of recovery support organisations who advocate twelve step style models, with or without higher power involvement.
The development of community based rehabilitation , and recovery orientated systems of care, have further developed the treatment process, encouraging  the recovering substance user to ”re-define their identity” (SRN 2007)  on their journey to social re-integration.

Critique of current treatments:

 The close relationship to the use of the medical model in the intervention stage reinforces the age old paradigm of addiction/substance misuse as a disease, a torch which zealously reinforces the twelve step recovery model and is utilised by advocates of the model to forward their own process of recovery. This process is embroiled in a dichotomy of needing the treatment services to supply their members for their organisations, but decrying the importance of treatment in the overall journey for the client.

Many research papers have however suggested that the process utilised by twelve step based support is no more successful than similar psychosocial interventions, and indeed one paper in particular(Goebert & Nishimura 2011) suggests that Americans of ethnic origin, actually utilise other services such as marriage counselling, to gain the same insight into their substance related issues, and tend not to favour twelve step model services when moving into recovery, instead relying on their own social circles.

Assessment is one of the many pillars modern treatment is based upon(Department of Health 2007), the utilisation of  assessment tools which assess both substance use and social inequalities can be found within most services, however Shewan and Dalgarno (2005), suggested in their paper that the discourse between service use and clinician, can be one of reinforcement of the social structure both people find themselves in, so this piece of work as well as other research into addiction as a social construct .( Peele,1998, Davies 2008) suggests that assessment may be flawed for this reason, and may not be an accurate reflection of substance use problems.

Few researchers disagree with the fact that at one point in the service users treatment plan they may need some form of intervention, and again researchers also agree that in some cases involving alcohol use/ especially at the dependent level of use, pharmacological intervention is needed to safely detoxify the person from alcohol. What does however cause discussion is the role recovery services have in dealing with those who spontaneously recover (Sobell & Sobell 1996), and those who wish to continue reduced drug use during and throughout recovery.

Standard belief systems within treatment and recovery are based on the client wanting to become, and stay abstinent, and needing help from clinicians, and recovery support networks to maintain that abstinent state via mechanisms such as sponsorship, and devolving responsibility to higher powers. These systems do not allow for natural recovery and often refuse to engage with the idea that it exists.

Research has suggested that spontaneous recovery is indeed a more normal state of affairs than twelve step groups would have you believe (sobell & sobell 1996), and that one thing it has in common with supported recovery networks are robust social networks which allow the service user to move away from their substance using past, as well as a change in circumstance and expectation behind the initial substance use, (Zinberg 1986).

Conclusion:

In order to answer the question “Which type of treatment works best in treating those with substance use problems?” I have briefly examined treatment and its two constituent parts, looking at the research which has critiqued the current thoughts and theories behind intervention and recovery maintenance, and how some research actually highlights weaknesses within the current paradigm. I have however to offer a balanced view, and if you read the research around the use of recovery networks, and the recovery movement, it does indicate that recovery is sustainable, it also indicates that treatment as a whole needs recovery and person centred care to be at its centre.(SACDM 2008).

Research also suggests that both medicalised treatment and psychological treatments need to be considered in deed several government documents state within their text that psychological and medical treatments should be considered part of the overall pathway for treatment of substance use problems, (Department of Health 2007, SACDM 2007) also highlighting that the “focus of the clinician treating the drug misuse is on patients themselves” (Department of Health 2007,)

When seeking to answer the above question, it appears that not one size fits all as it were, if you examine the current treatment provision there are many different treatment pathways available to people with substance use issues. In fact within the text of “Alcohol, No Ordinary Commodity, research & public policy “ it is stated that “there are more than 40 therapeutic approaches” for dealing with alcohol problems,(Babor et al 2010) .With so many treatments being available, it would be impossible to decide which specific treatment works best, however, after looking at the research, and the various reports on the value of community support (Miller, Meyers &  Hiller-Sturmhöfel, 1999) and balancing the research and evidence, one theme  seems to be common throughout successful treatment, and that is the use of social networks, or recovery capital. Another main theme in the literature seems to be the suggestion that personal responsibility is also a considerable aid in completing treatment successfully. (Prochaska & Di Clemente 1986)

I therefore submit that in answer to the question “Which type of treatment works best in treating those with substance use problems,” I would suggest that any treatment that is inclusive of behaviour change ideas, focuses on facilitating a person’s own journey into recovery, and accesses evidence based interventions relevant for that clients specific needs based on a holistic assessment should be deemed an effective treatment.

References:

Babor T et al (2010): Alcohol, No ordinary Commodity: research and public policy 2nd Edition Oxford University Press Pan American Health Organisation. 

Barker, P.; Buchanan-Barker P. (2005). The Tidal Model: A Guide for Mental Health Professionals. London: Brunner-Routledge

 Barker P.; Barker, PJ (2008). “The Tidal Commitments: extending the value base of mental health recovery”. Journal of Psychiatric and Mental Health Nursing 15 (2): 93–100. 

Berridge V (2012): The rise, fall and revival of recovery in drug policy: Lancet. 2012 Jan 7; 379(9810):22-3

Davies J.B (2009): The Myth of Addiction 2nd Edition Routledge London

Department of Health (England) and the devolved administrations (2007): Drug Misuse and Dependence: UK Guidelines on Clinical Management. London

Goebert D, Nishimura S. (2011): Comparison of substance abuse treatment utilization and preferences among Native Hawaiians, Asian Americans and Euro Americans: Journal of Substance Use April 2011: No 16(2) pp 161-170

Gori G.B. (1996): Failings of the Disease Model of Addictions. Human Psychopharmacology Volume 11  pp S33-S3

Gossop M. (2007) Living with Drugs 6th Edition  Ashgate Publishing Ltd.

Merril J.C , Menza M. (2002): Treatment of Drug Dependence in the Context of Traditional Disease Treatment Models. Psychiatric Services, Volume 53, No 12 pp1632-1633

Miller W.R , Meyers R.J  &  Hiller-Sturmhöfel S,(1999) : The Community Reinforcement ApproachAlcohol Research & Health Vol.23, No 2. P 116-120

Naidoo J & Wills J (2000): Health Promotion: Foundation for Practice Second Edition  Balliere Tindall Edinburgh

Peele S (1998) The Meaning of Addiction: An Unconventional View (1998 edition). San Francisco: Jossey-Bass,

Prochaska, JO; DiClemente, CC (1986). . Toward a comprehensive model of change. In: Miller, WR; Heather, N. (eds.) Treating addictive behaviors: processes of change. New York: Plenum Press

Rollnick S, Marson P, Butler C (2000) Health Behaviour Change : A guide for Practitioners: Churchill Livingstone Edinburgh

Sobell L.C, Cunningham J.A, Sobell M.B (1996):Recovery from Alcohol with or without Treatment: Prevalence in Two Population Studies:The American Journal of Public Health, July 1996 Vol.86 no.7 pp 996-972

Scottish Advisory Commision on Drugs Misuse (2008): Essential Care: a report on the approach required to maximise opportunity for recovery from problem substance use in Scotland

Scottish Government (2008) The Road to Recovery: A new Approach to tackling Scotland’s Drug Problem, The Scottish Government Edinburgh

 Scottish Recovery Network / NHS Education Scotland(2008)  Scottish Recovery Learning Materials

Shewan D, Dalgarno (2005): Evidence for controlled heroin use?  Low levels of negative health and social outcomes among non treatment heroin users in Glasgow (Scotland): evidence for controlled heroin use ? : British Journal of Health Psychology Vol. 10 No 1  pp 33-48

Wildholm J.J (2010): Extinction as a Model of Drug Treatment and relapse; A Behavioural Overview. The Open Addiction Journal No3 pp57-62

Zinberg , N (1986) : Drug ,Set And Setting: The Basis For Controlled Intoxicant Use  Yale University Press.

 

 

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