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By: Sharon Stancliff, MD, Medical Consultant
From the Manual for Primary Care Providers: Effectively Caring for Active Substance Users. Reprinted with permission from Dr. Sharon Stancliffe, MD and The Harm Reduction Coalition www.harmreduction.org
Substance abuse treatment is a field of medicine in which facts are sparse and opinions are plentiful. The fact that medical decisions are often made and/or constrained by those working in areas such as criminal justice, public assistance, and child welfare further complicates the issues. The purpose of this chapter is to assist the medical practitioner in understanding the options available to illicit substance users who present for care.This chapter will focus on harm reduction and on treatments for heroin and cocaine abuse.
When assessing a patient’s substance use, the interaction may be enhanced by an approach informed by harm reduction. That is, by asking oneself, “What is the most immediate, realistic option to prevent harm or promote wellness for this patient?” Response examples include education, access to syringes, referral to housing or food, or drug treatment.
For those seeking drug treatment, it is important to be aware that, while a variety of settings and modalities are available for patients seeking drug treatment, there are no well-documented guidelines for matching patients to medical and/or psychosocial treatments. It may be helpful, however, to have a basic understanding of substance use treatments that are available and the activities that can be expected in each setting. This information can help providers better understand what patients may experience and better assist patients in choosing treatment settings that fit with their needs.
Background
Substance use is not a new problem, but rather a long-standing social issue. Recent changes in medical policy have come about as we become more aware of the genetic and biological basis for addiction and treatment.
The Historical Context Of Substance Use
Until early in the 20th century, opioids (including heroin) and other drugs (including cocaine) were easily obtained from doctors or purchased over the counter. In the late 1800’s, the opioid-dependent person was most often a middle-class woman. As the addictive properties of these medications became known, their use declined significantly among this population. During this decline, less integrated groups, such as working class immigrants and minorities, began to use opioids recreationally, promoting stigma as well as regulation.
Laws regulating drug use have proliferated since that time, most notably in the Harrison Act of 1914. Prescription of opioids for purposes of maintaining an addiction was outlawed in 1919, resulting in the imprisonment of many physicians. Addicts (primarily dependent on opioids) were imprisoned, offered detoxification and other, often dangerous, interventions such as electroshock, lobotomy, and sterilization. The relapse rates for the serious opioid addict were as high as 90%. Observing this relapse rate, Vincent Dole, MD and Marie Nyswander, MD hypothesized that heroin addiction was a metabolic disorder and proposed maintenance treatment in the mid 1960s.
The Biological Basis Of Addiction
Emerging understanding of physiology and genetics suggests that individuals may be born with a predisposition to a disorder of the endogenous opioid system. The use of opioids and, very possibly, other environmental influences may then induce expression of the disorder. Therefore, opioid agonist treatment may be understood as replacement therapy, similar to the use of insulin in Type 2 Diabetes Mellitus.
Some Effects Of Opioids
Heroin and other opioids interact with receptors that are also the sites of action for endogenous opioid peptides, primarily the beta-endorphins. These receptors are found throughout the body, but are concentrated in the central nervous system. While the analgesic effects of opioids are believed to be mediated in the thalamus, much addiction research has focused on the “reward pathway” of the mesolimbic system. A dopamine pathway involving sites including the ventraltegmental area appears to mediate the rewards of vital activities such as eating and sex. Endogenous opioids mediate this pathway, which is in keeping with the observation that the drive to administer exogenous opioids can become as intense as basic life drives.
The Physiology Of Withdrawal
The physiological bases for acute withdrawal are not fully elucidated, but changes observed following chronic opioid administration include physical atrophy of dopamine-producing neurons in the ventraltegmental area. This shrinkage may be one reason why opioid users require increasing amounts of opioids in order to induce the euphoric effects. It is theorized that these and other long-term changes may lead to the anhedonia many opioid users experience with other previously pleasurable activities and may also explain why long term abstinence is so difficult for many opioid users.
The Role Of Genetics In Addiction
Genetics also has a role in the development of addiction. Studies of twins and adoption strongly suggest that high rates of alcoholism in some families have a genetic basis. While this connection is less well elucidated for other drugs, it is clear that addictive disorders are common in the families of heroin addicts.
Pharmacotherapy For Opioid Addiction
Opioid addiction can be treated in a variety of ways: with three types of medication—agonist, partial agonist, and antagonist, and through other modalities such as detoxification, Ultra Rapid Opioid Detoxification, and Clonodine.
Agonist Treatment For Opioid Addiction
In 1997, a National Institutes of Health Consensus Development Conference concluded that opioid agonist treatment, primarily methadone maintenance (MM), is a highly effective treatment for heroin addiction. In 1998, the federal General Accounting Office (GAO) report found that methadone maintenance is the most effective treatment for heroin addiction.
The majority of patients will stop using heroin if given a high enough dose of methadone. However, even at doses that may not extinguish heroin addiction, there are a number of benefits to treating patients addicted to opiates with methadone:
Another Replacement Therapy
Levo-Alpha Acetyl Methadol (LAAM)
LAAM is a long-acting derivative of methadone. Like methadone, LAAM is available only in Methadone Maintenance Treatment Programs (MMTP). The advantage of LAAM is that it needs to be taken only 3 times weekly; this allows less frequent clinic visits for patients who do not qualify for take-home doses. On the other hand, it will have an added regressive impact on those patients already “permitted” less frequent attendance since LAAM may not be given for take-home. LAAM is probably about as effective as methadone, though there may be lower retention rates.
Safety
LAAM’s side effect profile is the same as methadone’s with one possible exception. The FDA recently issued a “black box” warning about LAAM, and the possibility exists that it may [cause heart problems]….In Europe, LAAM has been banned because of this apparent problem.
The Role Of Counseling With Agonists
Like many patients with chronic illnesses, methadone-maintained patients might benefit from counseling to help them deal with their illness. However, MM is unique in that patients are required to receive counseling as a condition for receiving their medication. Despite this requirement, the medical literature has no agreement on what aspects of counseling are helpful; thus, there is little uniformity in training or goals. In addition, a trusting relationship between the patient and counselor is often difficult to establish in the MMTP setting given the fact that patients may lose “privileges” or even entitlements if they report a relapse or engage in any illicit activity. Finally, clinics often hire counselors who believe that the ultimate goal of methadone treatment is to discontinue treatment.
Misconceptions About Methadone
Misunderstanding
Methadone causes nodding or sedation.
Truth
People who are stabilized on a proper dose of methadone are not sedated by it. (A small minority of patients needs smaller doses of methadone twice a day to avoid sedation.) One common occurrence may contribute to this misconception: patients who are misusing benzodiazepines often attribute the resulting sedation to the legally prescribed methadone.
Misunderstanding
Methadone gets in the bones and harms them.
Truth
Perhaps this belief results from under-dosing of methadone. Some patients awake every day with a complaint of achiness, which is relieved by their methadone. Often a slightly higher dose will relieve this mild withdrawal. Methadone is not known to have any long-term adverse effects.
Misunderstanding
Methadone promotes the use of cocaine.
Truth
People start using cocaine at many times in their lives, some while on methadone. But…people initiating methadone treatment for heroin addiction are more likely to stop using cocaine.
Misunderstanding
It is harder to get off methadone than heroin.
Truth
With a proper taper one can stop taking methadone quite comfortably. When stopping abruptly, the withdrawal will be longer but milder as the half-life is longer. There is no rationale for stopping methadone prescribing abruptly
Misunderstanding
Methadone will harm a fetus.
Truth
It is safe during pregnancy and recommended instead of detoxification.
Antagonist Treatments For Opioid Addiction
The antagonist Naltrexone is used to treat opioid addiction. Naltrexone is an opioid antagonist that is administered orally several days a week. It blocks the effect of heroin but does not have any effect on craving. [NOTE: Although Naltrexone is effective, it has notoriously low retention rates in treatment, but studies indicate that when contingency management therapy (see article –) is included, retention rates significantly improve.
Safety Of Naltrexone
Naltrexone’s safety in the presence of liver disease has been questioned. Naltrexone also blocks the analgesic effects of opioid agonists. The oral form should be discontinued 72 hours prior to elective surgery. Unplanned surgery or trauma could lead to serious problems with pain management….
Another serious concern is emerging: high death rates among Naltrexone patients. A study recently released to the press prior to publication found that death rates among Naltrexone patients were significantly higher than among untreated addicts, apparently due to poor retention followed by high rates of heroin overdose at relapse of no longer tolerant individuals. This is consistent with the understanding that overdose is more common after a period of abstinence, but it is also possible that Naltrexone sensitizes receptors. This author has concern about a medication that does not reduce the powerful craving experienced by opioid addicts, but blocks satisfaction for an extended period.
Buprenorphine
Buprenorphine is a semi-synthetic, mixed opiate agonist-antagonist. Buprenorphine is clearly efficacious for some patients. [NOTE: More recent studies indicate its efficacy is on a par with lower doses of methadone but is not as effective in patients who require higher methadone doses. One advantage: it is available via physicians’ office based visits and does not require belonging to an MMTP.
Safety Of Buprenorphine
The significance of its mixed agonist-antagonist character is that there is a ceiling effect. The likelihood of respiratory depression is lessened, and withdrawal symptoms are thought to be lessened if abruptly withdrawn….
Detoxification
With the exception of pregnant women, detoxification with an attempt at abstinence is generally the first step for individuals who want to end their dependence on heroin. While all people who repeatedly administer an opioid will become dependent, it is unclear who or how many will be able to maintain long-term abstinence. Withdrawal may be done “cold turkey” with self-administered medications or with medical assistance.
Methadone Taper
Currently, licensed facilities offer a methadone “taper” to ease the withdrawal symptoms over the space of about 3-5 days for in patients, or over a much longer period of time for outpatients. There is only a fiscal—not pharmacological or empirical—rationale for the distinction.
Rapid Opioid Detoxification
In this procedure, withdrawal is hastened with intravenous administration of opioid antagonists while the patient is under various levels of sedation or anesthesia. The controversy surrounding this procedure is beyond the scope of this publication, but there is concern over the danger of anesthesia, particularly as there is no evidence that any particular method of withdrawal from heroin leads to greater likelihood of maintaining abstinence.
Clonidine
Clonidine, a centrally-acting alpha(2)-Adrenergic agonist, has also been used to ease withdrawal. While Clonidine is not easily tolerated, as it does not relieve all withdrawal symptoms and can cause significant hypotension, it is legal for any practitioner to prescribe clonidine for the purpose of withdrawal. The addition of naltrexone for several days may be helpful.
Psychosocial Treatments— see Psychosocial Treatments under Cocaine Addiction
Harm Reduction As An Approach To Treating Opioid Addiction
The keys to harm reduction in opioid addiction are syringe access, overdose prevention, and vaccination. While referral can be helpful for some patients, there are drawbacks. Not all patients want (or need) treatment; not all patients have access to treatment; and it is frustrating for both parties when the only available intervention is to ask the patient to go into treatment without considering all the options available to the patient.
Syringe Access
Use of sterile injection equipment, as recommended by the U.S. Department of Health and Human Services (USDHHS), is key to the prevention of blood-borne infections. Numerous health-related associations have called for the elimination of barriers to sterile syringe access, but availability is still not widespread.
Benefits Of Access To Sterile Syringes
Facilitating access to sterile syringes, whether by direct distribution or referral, encourages honest discussion between practitioner and patient. Patients may not have any other opportunity to discuss drug use and injection with someone knowledgeable about the health risks. These encounters may be more satisfying for the provider, who is often trained only to refer drug-using patients to drug treatment. Patients should also be informed about the role of hygiene in safer injection. Cleaning the injection site has been shown to reduce the risk of abscesses and endocarditis. Once the issue of disease prevention has been raised, further discussion about drug use may occur. In the discussion of drug use, patients who inject can also receive information on safe disposal.
All hospitals and nursing homes are required to accept household sharps. Properly packaged syringes may be placed in household trash.
Legally Obtaining Syringes
There are four options for legal access to sterile syringes in New York City: pharmacy sales, syringe exchange, furnishing of syringes by health care providers, and syringe prescription.
Overdose Prevention
Drug users should be made aware that heroin overdoses are more common after a period of abstinence such as drug treatment or incarceration. The majority of overdoses also occur when mixing drugs, both other depressants such as alcohol, benzodiazepines, or tricyclics and stimulants such as cocaine. Provision of naloxone and instruction in CPR have been suggested as preventive measures. Patients may benefit from advice to stay cool and hydrated, as fatal cocaine overdoses cluster in hot weather. Other countries have documented protection against overdose risk associated with safer injection facilities.
Vaccination
Hepatitis A54 and Hepatitis B vaccines are recommended for all illicit drug users and for non-monogamous adults. Patients should be assessed for indications for influenza and pneumococcal vaccines and an up-to-date tetanus status.
Treating Cocaine Addiction
Pharmacotherapy
Despite numerous trials, no pharmacotherapy has yet been shown to attenuate use or reduce craving. Many agents, including antidepressants and anticonvulsants, have been tried in the treatment of cocaine addiction; however, none has proven effective. This fact presents a major challenge, both to the user and the provider. [Ed note: Research continues to investigate the promise of disulfiram, a medication with dopaminergic effects, GABA medications such as tiagabine and topiramate, the beta-adrenergic blocker, propranolol, a stimulant medication, modafinil, and a cocaine vaccine that slows entry of cocaine into the brain. All hold some promise but require further testing].
Psychosocial Treatment. The extensive literature on psychosocial modalities supports only a few broad findings:
Harm Reduction: A Treatment Option
Some would argue that harm reduction is not “drug treatment” and, therefore, has no place in this chapter. However, if treatment is considered to be an intervention that may preserve or improve health, then harm reduction is central to drug treatment. Harm reduction is unique as an orientation in treatment in its history, its goals, its tenets, its benefits, and its approach to education.
The Goals Of Harm Reduction
Most traditional substance abuse treatment operates from the premise that the primary goal for problematic drug users is abstinence from drugs. Harm reduction, in contrast, is an approach to drug use that puts the well being of the user and society above the goal of abstinence.
The Tenets Of Harm Reduction
While there is no universally accepted definition of harm reduction, its proponents generally accept several tenets:
The Benefits Of Harm Reduction
Harm reduction recognizes that while abstinence is one means of reducing drug-related harm, a drug user’s major concern may not be the cessation of drug use. Many other goals may take precedence, including safety, shelter, avoidance of withdrawal, or recreation. Furthermore, little is known about why people use drugs compulsively even in the face of severe sanctions and acknowledged risks (as in the case of alcohol and nicotine). In any case, it is clear that patients can still benefit from medical interventions even though they continue to use drugs. It is also important to bear in mind that much drug and alcohol use is not out of control and does not reflect a “disease,” so “drug treatment” is not always indicated. However, education is often needed to prevent harm. Thus, harm reduction may benefit the health of recreational users, compulsive users, and the general public. For instance, the use of a designated driver when alcohol is consumed benefits the recreational drinker, the alcoholic, and teetotalers sharing the highway.
Harm Reduction In Historical Perspective
The roots of harm reduction are often traced to innovations in drug policy in the Netherlands in the late 1970’s and early 1980’s. The first syringe exchange was initiated in 1984 by injection drug users in Holland responding to an outbreak of Hepatitis B. As the role of injection drug use in the spread of HIV became clear, harm reduction policies, including syringe exchange programs (SEPS), the expansion of methadone prescribing, and outreach were rapidly expanded in some parts of Europe. It has been argued that these policies are responsible for the low rates of HIV in much of the United Kingdom.
In contrast, the United States has been reluctant to develop these policies. However, in 1992, in New York State, the Commissioner of Health, under regulatory authority, granted waivers to some not-for-profit organizations to conduct syringe exchange programs within the context of a harm reduction model of HIV prevention. A demonstration project to sell syringes over the counter was initiated in 2001.
The Role Of Education In Harm Reduction
Education is the backbone of harm reduction. When drug users are educated about the risks involved in drug use and are offered tools to reduce these risks, it is apparent that many alter their behavior. As noted above, drug users were the first to propose the establishment of syringe exchange. The incidence of both HIV42 and Hepatitis C has dropped since universal precautions and education became widespread in the United States.
On the other hand, health care providers have educational needs as well:
Some of this information may be found in sources such as this manual. But in order to assist patients in integrating such knowledge into their lives, providers must also be willing to learn from their patients.
Nonpharmacological Drug Treatments
Drug treatment is offered in a variety of settings. Most settings admit patients using any illicit substance or alcohol. Many of these settings are residential, with admission ranging from four days to a year or more. Child care, family responsibilities, and jobs (even “off the books”) may pose legitimate obstacles to participation.
Nonpharmacological drug treaments include detoxification, short term inpatient treatment, outpatient non-methadone treatment, long term residential treatment, and AIDS residences.
Detoxification
Inpatient “detoxes” are hospital-based units in which patients can be monitored and/or medicated as they are withdrawn from drugs. This step is usually required before entry into treatment programs, except methadone maintenance, which patients may enter directly. Most “detoxes” include lectures, twelve-step groups, individual counseling, and referral for further treatment after acute withdrawal is completed.
Detoxification Programs For Different Substances
Detoxification Program Concerns
In response to concerns over the efficacy and cost of “detoxes,” many programs have shortened their lengths of stay or offered services on an ambulatory basis. Some insurance companies are refusing to pay for cocaine detox because the drug does not produce a dangerous withdrawal syndrome, and long-term abstinence following a brief detox episode is rare. While a brief stay in detox rarely leads to abstinence, visits to detox may be a form of harm reduction—people take a break from drug use and reduce their habits. It is important to note, however, that heroin overdoses are most common after a period of abstinence.
Short-Term Inpatient Treatment
Generally known as “rehabs,” these intensive programs generally last 28 days. The programs are highly structured, and are usually based on the twelve-step model. Patients receive individual counseling, group therapy, and classroom work, with lectures on substance use and relapse prevention. Unlike the long-term residential treatment, rehabs usually place less emphasis on housekeeping and discipline and often have more professionally trained staff.
Long-Term Residential Treatment
Residential services are designed to help the person who is unable to achieve abstinence in the community setting. The majority of these facilities are “therapeutic communities” (TCs) or “modified therapeutic communities.” TCs are highly structured residential settings based on self-help and the concept of addiction as a learned response. Residents are typically subjected to an environment that incorporates interventions intended to break down the acquired personality traits believed to support their addictions, while providing the basis for a new and drug-resilient personality. There are specific rewards for appropriate behavior. Rewards include increased freedom or responsibility, while punishments for unacceptable behavior include restrictions or demeaning tasks. Residents are responsible for most of the daily maintenance. These tasks are considered to be an integral part of the therapy. Senior residents may have responsibility for supervising newer residents, and graduates often become staff members.
Program Elements
Programs may include counseling, classes, group therapy, work, vocational counseling, and job training and placement. The majority of these programs have begun to offer and encourage twelve- step participation, and some have added more professionally trained staff into the peer model….
Program Concerns
Areas of concern include possible humiliation of patients, low retention rates, and a philosophical stance against opioid agonist maintenance.
Humiliation Of Patients
When making referrals to residential treatment, it is important to be aware that many of these settings use highly confrontational approaches and punishments that are often humiliating. While many graduates of these programs believe the structure was helpful, many persons seeking drug treatment have already been through a great deal of censure, and more of the same in the name of treatment may be detrimental.
Low Retention Rates
Retention rates are not documented to be high in therapeutic communities; yearly retention has been found to be 10-30%. In addition to dropping out, patients are also administratively discharged, often for relapse to drug use as well as a host of other unacceptable behaviors. Drug courts often mandate users to TCs, so some of these facilities include significant numbers of residents who have not entered voluntarily….
Philosophical Stance Against Maintenance Treatment
Although several TCs offer “methadone-to-abstinence”—a gradual taper stretched over weeks to months, the overwhelming majority of TCs bar opioid agonist maintenance on philosophical grounds. This severely limits treatment options for methadone patients who either believe they may benefit from intensive psychosocial treatment or who have been mandated by official agencies to residential treatment. The legal and ethical basis for such discrimination against patients receiving a prescribed medication has been questioned.
Selected Additional Drug Treatment Modalities
Additional treatment modalities include acupuncture, twelve-step programs, cognitive behavioral therapy, and contingency management.
Acupuncture
Acupuncture is offered in many settings—most commonly as simplified auricular acupuncture. Patients have needles inserted in several points in the ear at least several times a week for some period of time. An NIH Consensus Statement found that there is sufficient evidence to suggest that this procedure may be a helpful adjunct to other forms of drug treatment. A more recent study suggested that patients randomized to auricular acupuncture versus relaxation or a needle insertion control group were less likely to use cocaine over the period of 8 weeks.
12-Step Programs
Twelve-step programs include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA). The “Twelve-Step Movement” grew out of a Christian organization known as the Oxford Group. Traditional “twelve-Step” groups such as Alcoholics Anonymous (the first), Narcotics Anonymous, and Cocaine Anonymous are based on a series of principles and associated actions (the “steps”). Members are encouraged to admit their “powerlessness” over the use of drugs, accept that a “higher power” is the only thing that can help them, and pledge that they will carry the message to others. Participants attend anonymous meetings in which they share experiences and work through the steps.
Potential Concerns
For patients with a different cultural perspective, some of the tenets of “twelve-step” may not fit within their value systems, and others may reinforce already low self-esteem.
Program Efficacy
Although many people report finding these groups helpful, empirical studies on the efficacy of self-help vary in their findings. Attendance at twelve-step programs following drug treatment is often associated with less substance use, but the cause-effect relationship is questionable. Some randomized studies have actually found worse outcomes among alcoholics attending AA; the conclusion was that coerced subjects biased the data. Patients should be informed of twelve-step programs, but there is insufficient evidence to insist that they take part in them if the patient does not feel it would be helpful.
Cognitive Behavioral Therapy
This modality is essentially “relapse prevention.” In group or individual sessions, participants focus on the positive aspects of abstinence and the negative aspects of use. In this context, situations which may lead to use are considered, and coping skills are devised.
Contingency Management
Patients may be rewarded for abstinence or punished for drug use. In clinical trials, these rewards can include paying patients with vouchers for clean urines. In reality, contingency management is practiced constantly—from the reward of take-home medication in methadone clinics when patients stop using all drugs, to incarceration for continued drug use.
Conclusions
Instead of the standard method of simply referring all substance users into treatment, the primary care provider, as well as the patient, stands to benefit from an engaging communication with regard to the patient’s substance use. A realistic goal for most substance users is reduction of preventable harm, either through treatment or using the tools of harm reduction.
Patients who want or are being pressured to enter treatment may be offered guidance in choosing the treatment modality most appropriate to their needs. Many patients may not be immediately successful in changing their pattern of substance use. While many people reduce or stop drug use, it should be noted that few treatments have solid track records of successful outcomes. An exception is methadone maintenance, which is not only proven to reduce heroin use, but also to reduce the transmission of HIV and the risk of overdose. Given the effectiveness of methadone maintenance, all heroin users should be made aware of these benefits, despite the significant drawbacks in the clinic system.
Health care practitioners who are willing to listen to their patients wishes can offer meaningful assistance to patients who use drugs— whether or not the goal is abstinence.