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TREATMENT OPTIONS

Fortunately today, there is a range of treatment options available in the field of addictions. Addicts and their families need to familiarise themselves with these different options. Numerous factors must be considered for the best choice to be made. The following information should be considered as a guide only. Further information should be obtained from accredited health professionals.

Methadone
Methadone is a synthetic opiate. It is not a “blocker” which means that it does nothing to reduce the cravings for heroin. Instead, it replaces heroin and is no less a drug of dependence than heroin. Indeed, it is more addictive than heroin. Withdrawing from methadone is far more difficult and painful than withdrawal from heroin.
Methadone does not resolve the underlying issues which are responsible for addiction. It simply shifts the addiction from an illegal and dangerous opiate to a synthetic alternative which, if taken as directed, is considered safe.
However, a closer look at methadone suggests a number of pluses and minuses.

On the positive side:
Methadone does not involve injections and therefore avoids the risks of septicaemia, endocarditis, hepatitis B & C and HIV from shared or dirty needles.
The addict on methadone usually has regular contact with healthcare professionals who are trained, experienced and resourced to help people with addiction and associated problems. They also know when to refer addicts to other appropriate consultants or agencies which may help further.
Addicts on methadone may develop a comparative stability in their life including job stability, unlike during their roller-coaster existence of chasing and using heroin. This increased stability may greatly benefit them and their position in life.
Accidental overdosing with methadone alone is unlikely with the usual program. However, combining other narcotics such as benzodiazepines or alcohol with methadone may result in the death of the patient.
Methadone is a very effective physical pain killer and may be better than detoxification and naltrexone, at a time of strong physical pain that would take time to be controlled by other means.
Methadone is now available through many government clinics and is usually subsidised or free. This removes the need for lying, cheating, stealing, armed robbery, drug-dealing and prostitution to get heroin. It diminishes the impact on both the addict and the rest of the community by reducing organised crime, and also by taking some of the pressure off overstretched law-enforcement resources.

On the negative side:
Methadone is a very powerful addictive drug - the patient is still an addict and may continue to be part of the drug scene. Many addicts really dislike methadone for reasons that they may not be able to fully explain, but mainly because it is much harder for them to withdraw from it than from heroin. They are often very upset by the fact that they did not fully understand this before they went on methadone, even though most were probably told.
Whilst using methadone, the addict may still crave and still use other narcotics. Methadone, especially as part of poly-drug abuse is still a potentially fatal substance.
Unless addicts on methadone clean their teeth several times a day, these may decay rapidly. The loss of teeth may require dentures which are difficult for them to get. This can greatly affect their self-esteem and self-confidence, aggravating the whole situation.
Addicts on methadone are comparatively tied down as they have to report to the same pharmacist daily to get their dose. This may interfere with jobs, job seeking or other important matters.
Some patients report other important problems such as severe chronic constipation, fluid retention, weight gain, drowsiness, loss of concentration, poor memory and debilitating lack of motivation. These problems can cause them to seriously regret going on methadone and to resent the authority which advised them to do so.
Clearly, methadone is one option that addicts need to consider, but like every option, it must be viewed within the context of all its pros and cons.

Buprenorphine
Unlike methadone which maintains the addiction, buprenorphine acts as a “blocker” as well as having moderate narcotic effects. People on an adequate dose of buprenorphine very seldom crave or use heroin because it both blocks nerve receptors and is a narcotic replacement chemical.
It is not nearly as powerfully addictive. It is a drug of addiction but not nearly as addictive as methadone.
It has been alleged that up to 50% of people on methadone continue to use heroin or other narcotics intermittently or regularly. They still crave the euphoria of heroin or morphine, and methadone doesn’t stop them from experiencing these cravings because it is not a “blocker.” In contrast, buprenorphine is a powerful blocker as well as having moderate narcotic effects.
Buprenorphine doesn’t rot your teeth and make you embarrassed or frightened to smile..
It is not as sedating as methadone and you are therefore normally alert with more normal powers of memory and concentration. You remain more normally motivated and able to do things. Buprenorphine does not usually cause chronic constipation, excessive fluid retention or weight gain.
A dose of buprenorphine is effective for more than twice as long as a dose of methadone, so most patients are not as tied down by it. Most can visit their pharmacy to pick up a does of buprenorphine every second day, rather than every day. Some patients have reported that they could last three days on one dose.
There appear to be very few disadvantages associated with buprenorphine. It may be a little more expensive than methadone but is still comparatively economical and affordable. Minor problems have allegedly been reported with the illicit use of buprenorphine as an alternative to heroin. This is a small price to pay for all its benefits, and this problem can be managed. A few chemically disturbed people may seem unable to live without narcotics, and buprenorphine appears to be by far the least damaging alternative for these people, their families and the community.
Buprenorphine can also be combined with naloxone in tablet form. This is known as suboxone. Naloxone is an opiate antagonist. This means that it blocks the opiate receptors in the brain and subsequently the drug’s effects.

Naltrexone
By nullifying the effect of heroin on the brain, naltrexone stops the craving for narcotics. Once the right dose is found, it stops narcotics from having any effect if they are used. However, if the underlying issues which have contributed to the addiction are not resolved, the user will be in great danger of stopping naltrexone and reverting back to heroin quickly.
At the same time, it does not remove the desire to exp-erience heroin; addicts using naltrexone are still vulnerable to the pursuit of heroin for this reason.
Naltrexone can only be administered to a person who is drug-free. This can be achieved through various forms of detoxification, including the more recent and popular ‘rapid opiate detox’ method whereby the addict is detoxified rapidly overnight. Using heroin while taking naltrexone can be dangerous, even fatal. It is therefore essential, as is the case with other chemical remedies, that the treatment is accompanied by counselling and therapy as well as a strong support system.
A note of caution, regarding the rapid detoxification method. Although this method is effective in removing the opiate toxins from the body, it does not address any of the psychological or other factors associated with addiction. As an addict continues to use drugs, his ‘tolerance level’ - the level at which he feels a benefit from the drug - rises, leading to an increase in his drug intake. Following rapid detoxification, this tolerance level drops right down and the addict may be at risk of overdosing, even on small quantities of drugs. For reasons other than the physical need associated with drugs, he may still be tempted to use, placing himself at greater risk. Rapid detoxification must be considered within a supportive environment so that the addict is protected from any form of drug usage during the early days following the treatment.

The Therapeutic Community
Therapeutic communities offer addicts the option to remove themselves completely from the drug scene and cut their ties with other addicts and dealers. Most therapeutic communities are situated outside urban areas in order to place the addicts away from their former environment.
They provide a substantial opportunity for the addict to participate in extensive counselling, as well as group work. Some are staffed by former addicts who serve as role models once they have been able to kick their habit. Peer group environment is essential for the community to enable residents to reinforce one another’s progress.
Critics of the therapeutic community model argue that it simply serves to protect the addict from the reality of life in the real world. Others argue that the therapeutic community is not a good choice for addicts who still enjoy a place in the workforce or for those who have partners or children. Losing a work opportunity or further straining family ties can be threatening.
Whilst some people may argue that participation in a therapeutic community is a cop-out, others will agree that the very readiness for an addict to devote six months to full-time rehabilitation is the strongest endorsement of their genuine awareness of the seriousness of their addiction - a significant step on the road to recovery.
Bearing in mind some of these issues, in recent years there has been a shift from the long-term program (six months to a year) to shorter or medium term programs (four weeks to several months). With the introduction of various medical therapies such as naltrexone and buprenorphine, as well as a general shift toward community based models for treatment, it will be interesting to observe the effects these changes have on the popularity of therapeutic communities.

Counselling and Therapy
Counselling and therapy as well as group process form an integral part of any effective recovery program. There are numerous approaches that different practitioners adopt in order to work effectively with their patients.
Counselling has been shown to be more effective when it is ongoing. A non-judgemental approach encourages addicts to be more honest about their addiction. Counselling of addicts can be particularly difficult as many of them genuinely doubt their ability to become drug-free. Empowering the addict and creating a sense of optimism significantly assist the therapeutic process.
The counsellor may be the first person in years in whom the addict can place his trust. For some of them, counselling becomes a testing ground within which the addict can be honest to both himself and the counsellor. This is an important step in the recovery process.
Most counsellors work towards the development of a treatment plan for the addict. A family based approach will facilitate sessions involving the parents and also other members of the family when relevant. The treatment plan may involve various people, as it may be impractical for the same person working with the addict to also work with the family and others.
Ideally, the treatment plan includes the opportunity for review so that both the counsellor and others involved in the process have the opportunity to discuss their progress and attend to any issues which may be relevant to the counselling process.

Group Therapy
There are numerous reasons why group therapy is an important tool in the recovery process. Because interpersonal relationships are a significant issue for the recovering addict, group therapy provides a safe setting within which these issues can be addressed. It removes the sense of isolation experienced by the addict and assists in the validation of his feelings and experiences. In doing so, the process assists in correcting the addicts’ distorted view of the world. At the same time, by learning that they are not unique in their problems, addicts are able to face the recovery with a greater sense of confidence.
The feedback received from members of the group assists the addict in learning which behaviours are acceptable. As the group members interact with each other in a mutually supportive forum, a sense of trust is created.
As the group members are able to develop mutual trust, they experience a sense of cohesion and belonging. For many former addicts, this represents the first time in many years, where they are able to feel accepted and protected. They can deal with confrontation, knowing that they will not be harmed. These feelings, in turn, serve to create the backdrop within which the group members can explore issues of intimacy and closer inter-personal relationships.
As feelings are experienced and shared, group members are able to learn how to identify and best manage them. Instead of having those feelings masked by a chemical substance, the former addict is able to behave and respond in a supportive and safe environment. As the group members role-play new experiences, they become more confident about their ability to communicate effectively and interact appropriately with friends, family and the community.

 

The Twelve Steps Approach - Alcoholics Anonymous & Narcotics Anonymous

Most people are familiar with or at least have heard of AA or NA. Alcoholics Anonymous is the best-known and largest self-help program. It has been the model for other 12-Step programs. Alcoholics Anonymous began in 1935 in Akron, Ohio, with the meeting of two alcoholics. One was Bill W. who had a spiritual experience which was a major precipitating event and the beginning of his abstinence from alcohol. After Bill W. had been sober for about a year, he went on a business trip and was hit with a strong desire or compulsion to drink. He hit upon an idea of seeking out and talking with another suffering alcoholic as an alternative to that first drink. He reached out for help, made contact with some people and they led him to Dr. Bob (another alcoholic). Bill W. and Dr. Bob met and started a fellowship which is now famous as their first meeting. In the years that followed, a simple structure was written down as a guide. It is referred to as the 12 Steps:

1. We admitted we were powerless over alcohol and that our lives had become unmanageable.
2. We came to believe that a Power greater than our-selves could restore us to sanity.
   
3. We made a decision to turn our will and our lives over to the care of God, as we understand him.
   
4. We made a searching and fearless moral inventory of ourselves.
   
5. We admitted to God, to ourselves and to another human being the exact nature of our wrongs.
   
6. We were entirely ready to have God remove all these defects of character.
   
7. We humbly asked Him to remove these short-comings.
   
8. We made a list of all the persons we had harmed, and became willing to make amends to them all.
   
9. We made direct amends to such people wherever possible, except when to do so would injure them or others.
   
10. We continued to take personal inventory and when we were wrong promptly admitted it.
    
11. We sought, through prayer and meditation, to improve our conscious contact with God as we understand him, praying only for knowledge of His will and the power to carry that out.
12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to others, and to practice these principles in all our affairs.

The cornerstone of the AA model is the paradoxical belief that to gain control of one’s life, one must give up control to a higher power. Although AA distinguishes between spirituality and religion, it advances the belief that addiction is both a physical and spiritual disease. AA has been referred to as a spiritual program for living.
Central to the AA program are five fundamental aspects:
(a) learning to give up control to gain control
(b) self-examination and discussion of this examination
(c) making amends
(d) group participation
(e) daily reminders
As one of the most successful components of recovery from addiction, it is worth noting that in 1990, the fellowship involved 15 million individuals in over 500,000 groups in 114 countries.

 

The Twelve Steps of
Dual Recovery Anonymous (DRA)

DRA began to form in Kansas City in the U.S. in 1989. The members were men and women who experienced a dual disorder. Their goals were simple:
Apply the principles of the Twelve Steps to both their chemical dependency and their emotional or psychiatric illness.
Provide meetings where members could openly discuss recovery issues regarding both their illnesses with other members who could relate to their experiences, and offer one another support.
Carry the message of recovery to others who experienced dual disorders and help develop DRA as an organisation that could offer assistance to others who wish to establish DRA groups.
DRA is an independent, non-profit, non-professional, self-help organisation. DRA was established to help men and women who experience a dual disorder. This occurs when an individual is affected by both chemical dependency and an emotional or psychiatric illness.
The primary purpose of DRA is to help one another achieve dual recovery, to prevent relapse, and to carry the message of recovery to others who experience the same disorder. The DRA program is based on the principles of the Twelve Steps and the personal experiences of men and women in dual recovery. DRA expects members to express a desire to stop using alcohol and other intoxicating drugs, as well as a desire to manage one’s emotional or psychiatric illness in a healthy and constructive environment.
Like AA, there are no charges, dues, or fees for DRA membership. New-comers do not need a referral from a professional service provider.

The Twelve Steps of DRA are:

1. We admitted we were powerless over our dual illness of chemical dependency and emotional or psychiatric illness - that our lives had become unmanageable.
   
2. Came to believe that a Higher Power of our under-standing could restore us to sanity.
   
3. Made a decision to turn our will and our lives over to the care of our Higher Power, to help us to rebuild our lives in a positive and caring way.
   
4. Made a searching and fearless personal inventory of ourselves.
   
5. Admitted to our Higher Power, to ourselves, and to another human being, the exact nature of our liabilities and assets.
   
6. We’re entirely ready to have our Higher Power remove all our liabilities.
   
7. Humbly asked our Higher Power to remove these liabilities and help us strengthen our assets for recovery.
   
8. Made a list of all persons we had harmed and became willing to make amends to them all.
   
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
   
10. Continued to take personal inventory and when wrong, promptly admitted it, while continuing to recognise our progress in dual recovery.
    
11. Sought through prayer and meditation to improve our conscious contact with our Higher Power, praying only for knowledge of our
12. Higher Power’s will for us and the power to carry that out.
    Having had a spiritual awakening as a result of these Steps, we tried to carry this message to others who experience dual disorders and to practice these principles in all our affairs.