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Treatment of Substance Dependence
Abstract
Substance dependence is recognized in the scientific community to be a medical condition rather than a willful misbehavior, but in societies and in politics a connotation of moral weakness, of irresponsible behavior or even of criminal intent can be observed, in attitudes and arguments and in a stigmatization of addictive behavior. Therefore, treatment of substance dependence must respect both the individual and the societal values at stake, in designing and implementing therapeutic approaches, avoiding neglect as well as undue coercion. The empirical evidence on what can be achieved, for whom and under what circumstances, is the basis of treatment, in line with the principles of consequential ethics, of human rights and of medical ethics in general. The implementation of these principles, however, is affected under the conditions of war or similar disasters. Also, health policy has to minimize the risk factors for and the negative consequences of substance dependence, as well as the negative consequences of non-dependent substance use (e.g., accidents under the influence of alcohol) besides providing treatment and care. This is evidenced in a confrontation of two major types of drug policy: namely an abstinence-oriented prohibitionist drug policy on one side, and a risk of use reduction oriented policy on the other side.
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Studies of community-based substance abuse treatment indicate that motivation for treatment is critical for retaining clients in the program and for their becoming therapeutically engaged in the recovery process. Relatively little work, however, has examined the effect of motivation on therapeutic engagement in criminal justice settings. Baseline and during-treatment data were collected prospectively from 419 probationers remanded to a 6-month modified therapeutic community. Findings showed that desire for help and treatment readiness were associated with indicators of therapeutic engagement even after statistically controlling for additional factors that could have confounded these relationships. Targeted readiness and induction interventions are therefore recommended for offenders with low motivation who are remanded to treatment in correctional settings.
The continuing threat posed by HIV, HCV, drug overdose, and other injection-related health problems in both the United States and Canada indicates the need for further development of innovative interventions for drug injectors, for reducing disease and mortality rates, and for enrolling injectors into drug treatment and other health care programs. Governmentally sanctioned “safer injection facilities” (SIFs) are a service that many countries around the world have added to the array of public health programs they offer injectors. In addition to needle exchange programs, street-outreach and other services, SIFs are clearly additions to much larger comprehensive public health initiatives that municipalities pursue in many countries. A survey of the existing research literature, plus the authors' ethnographic observations of 18 SIFs operating in western Europe and one SIF that was recently opened in Sydney, Australia, suggest that SIFs target several problems that needle exchange, street-outreach, and other conventional services fall short in addressing: (1) reducing rates of drug injection and related-risks in public spaces; (2) placing injectors in more direct and timely contact with medical care, drug treatment, counseling, and other social services; (3) reducing the volume of injectors' discarded litter in, and expropriation of, public spaces. In light of the evidence, the time has come for more municipalities within North America to begin considering the place of SIFs in public policy and health initiatives, and to provide support for controlled field trials and demonstration projects of SIFs operating in injection drug-using communities.
This document presents the report of the external evaluation of the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts that were conducted in three phases between 1995 and 1998. The Swiss Scientific Studies are hereinafter referred to as the Swiss studies. - The Swiss studies were designed and initiated in the early 1990s as a response to difficult local problems of populations of addicts who appeared to be refractory to, and unable to engage with, the treatments then currently available. - The Swiss Federal Office of Public Health (SFOPH) and the research team chose to conduct a direct observational study to assess the feasibility of heroin and other opioid prescription, to assess the suitability of the treatment method for heroin addicts who had failed at other treatments, and to assess the impact of such treatment on health and social outcomes. - Unlike drug treatment systems in most other countries, the Swiss drug treatment system is highly resourced with high levels of drug-free residential and drug-free community treatment as well as high levels of oral methadone treatment. - The Swiss studies had a very high degree of oversight involving local Canton authorities, federal authorities and researchers from the Institute for Social Research. Reports of all deaths were reviewed and none found to be related to the nature or quality of treatment. However, these reports have not been reviewed independently by the external evaluators. - The questions and priorities for the Swiss authorities at the beginning of the project were different from those subsequently raised at an international level. The final study design was a prospective outcome study that was intended to measure the impact of the intervention but could not determine the efficacy of one intervention compared to other interventions. - The Swiss studies were not able to examine whether improvements in health status or social functioning in the individuals treated were causally related to heroin prescription per se or a result of the impact of the overall treatment programme. Hence, from a rigorous methodological viewpoint, it was not possible to obtain internally valid results with respect to the research question of heroin prescription being causally responsible for improvements in health status or social functioning in the individuals treated. - The external evaluation supported the study conclusions that: (1) it is medically feasible to provide an intravenous heroin treatment programme under highly controlled condition s where the prescribed drug is injected on site, in a manner that is safe, clinically responsible and acceptable to the community; (2) participants reported improvements in health and social functioning and a decrease in criminal behaviour and in reported use of illicit heroin. - There is a need for continued scepticism about the specific benefits of one short acting opioid over others and there is a need for further studies to establish objectively the differences in the effect of these different opioids.
Offers transtheoretical therapy as one alternative when seeking a synthesis for the increasing proliferation of therapeutic systems. From a comparative analysis of 18 leading systems, 5 basic processes of change were identified by the present 1st author (1979). They are consciousness raising (feedback, education), conditional stimuli (counterconditioning, stimulus control), catharsis (corrective emotional experiences, dramatic relief), choosing (self-liberation, social liberation), and contingency control (reevaluation, contingency management). Each process can be applied at the level of either the individual's experience or environment. The present authors (see record
1982-31158-001) have identified the following stages of change: contemplation, termination, action, and maintenance. The verbal processes of change—consciousness raising, catharsis, and choosing—are most important during the 1st 2 stages, while behavior therapies (conditional stimuli and contingency control) are needed once a commitment is made. It is suggested that in the transtheoretical model, cognitive restructuring is seen as the result of the individual effectively applying the appropriate processes of change during each of the appropriate stages of change. (27 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Our objective was to determine the prevalence and incidence of human immunodeficiency virus (HIV) infection and related risk behaviors among opiate-abusing intravenous drug users (IVDUs) either in or out of methadone treatment. The subjects, 152 in-treatment and 103 out-of-treatment intravenous opiate users, were followed prospectively for 18 months. Behavioral and serologic assessments were made at 6-month intervals, with complete information available on 89% of the sample. Subjects were recruited from a single methadone maintenance program and the surrounding neighborhood in north-central Philadelphia. At baseline, the HIV seroprevalence rate for the total sample was 12%: 10% for the methadone-maintained group and 16% for the out-of-treatment group. Out-of-treatment subjects were injecting drugs, sharing needles, visiting shooting galleries, and practicing unsafe sex at significantly higher rates than in-treatment subjects. Follow-up of HIV-negative subjects over the next 18 months showed conversion rates of 3.5% for those who remained in methadone maintenance versus 22% for those who remained out of treatment. The sixfold difference in rate of seroconversion between the two groups suggests that although rapid transmission of HIV still occurs, opiate-abusing IVDUs who enter methadone treatment are significantly less likely to become infected. In contrast, those opiate addicts who do not enter treatment are at significantly higher risk of contracting and spreading the disease. Implications for developing additional risk interventions for out-of-treatment IVDUs are discussed.
(C) Lippincott-Raven Publishers.
Motivational interviewing is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship. This article seeks to define motivational interviewing and to characterize its essential nature, differentiating it from other approaches with which it may be confused. A brief update is also provided regarding (1) evidence for its efficacy and (2) new problem areas and populations to which it is being applied.
Marijuana policy analyses typically focus on the relative costs and benefits of present policy and its feasible alternatives. This essay addresses a prior, threshold issue: whether marijuana criminal laws abridge fundamental individual rights, and if so, whether there are grounds that justify doing so. Over 700,000 people are arrested annually for simple marijuana possession, a small but significant proportion of the one hundred million Americans who have committed the same crime. In this essay, we present a civil libertarian case for repealing marijuana possession crimes. We put forward two arguments, corresponding to the two distinct liberty concerns implicated by laws that both ban marijuana use and punish its users. The first argument opposes criminalization, demonstrating that marijuana use does not constitute the kind of wrongful conduct that is a prerequisite for just punishment. The second argument demonstrates that even in the absence of criminal penalties, prohibition of marijuana use violates a moral right to exercise autonomy in personal matters - a corollary to Mill's harm principle in the utilitarian tradition, or, in the non-consequentialist tradition, to the respect for personhood that was well described by the Supreme Court in its recent Lawrence v. Texas opinion. Both arguments are based on principles of justice that are uncontroversial in other contexts.
European policy and practice in caring for people living with addictions is based on defined values (human rights, medical ethics) and on research evidence for the effects and impact of interventions. The focus of the paper is on risk management approaches to reduce the negative consequences of continued illicit drug use, being the ethically most debatable issue. The legal and policy positions are set by the European Council and Commission, and their translation into practice is documented centrally in the European Monitoring Centre on Drugs and Drug Addiction, showing the general trends as well as national differences. The European experience with the risk management approaches is presented in terms of research evidence on their effects and side-effects; this evidence is justifying the present practice. The perspectives for the future are set to follow the same lines, in a continued effort to find a balance of interests, in cooperation of authorities and civil society, and guided by ongoing research.
Switzerland introduced a pragmatic national drug policy when the former conservative abstinence-orientated politics proved unable to cope with an escalating number of users and related negative consequences for public health and public order. The high visibility of 'needle parks' and the size of the acquired immune deficiency disorder (AIDS) epidemic called for a new approach and for national leadership.
To describe the intentions, the process and the results of setting up the new treatment approach of prescribing heroin to treatment resistant heroin addicts, as an example of drug policy change.
A systematic collection of relevant documents is analysed and used as evidence for describing the process of policy change.
Measures to reduce the negative consequences of continued use and to prevent the spread of AIDS were started mainly by private initiatives and soon taken up officially in the 'four-pillar' drug policy (including harm reduction, prevention, treatment and law enforcement). Medical prescription of heroin to chronic, treatment-resistant heroin addicts was one of the innovations, based on extensive scientific and political preparation. Detailed documentation and evaluation, ample communication of results, adaptations made on the basis of results and extensive public debate helped to consolidate the new policy and heroin-assisted treatment, in spite of its limitations as an observational cohort study. All necessary steps were taken to proceed from a scientific experiment to a routine procedure.
Comparable policy changes have been observed in a few other countries, such as The Netherlands and Germany, based on the Swiss experience, with equally positive results of heroin-assisted treatment. These experiments were designed as randomised controlled trials, comparing intravenous heroin against oral methadone, thereby demonstrating the specific value of pharmaceutical diamorphine for maintenance treatment in opiate dependence. The positive impact of policy change and the positive outcomes of heroin-assisted treatment were acknowledged increasingly nationally and internationally, but made it difficult to continue the process of adapting policy to new challenges, due to the low visibility of present drug problems and to changing political priorities.
A major change in drug policy was effectively realised under typical conditions of a federalist country with a longstanding tradition of democratic consensus building. Facilitating factors were the size and visibility of the heroin problem, the rise of the Aids epidemic, and a pragmatic attitude of tolerating private initiatives opening the way to official policy change.
Continued education of professionals is a major factor for service improvement and evidence-based good practice. This project explores the strategies used for this purpose across countries (CET = continued education and training in the substance abuse field). A structured questionnaire was circulated internationally by an expert committee of the Swiss Federal Office of Public Health. Reports from 11 countries were collected in 2005. The following review is based on these reports and structured according to the questionnaire (questions in italics). The authors of the reports are listed in the acknowledgements. The countries are Australia, Austria, Finland, France, Germany, Greece, Italy, The Netherlands, Scotland, Switzerland, and the United States. As a result of this project, an international think tank on continued education and training was established and is briefly described.
Methadone maintenance treatment is probably the most evaluated form of treatment in the field of drug abuse treatment and continues to arouse professional and political controversy. Possible benefits of oral methadone treatment range from impact on illicit opiate use and injection related risktaking behaviour to reductions in the level of criminal activity and other positive social changes. The most important active ingredient of treatment has been debated: is it simply the: provision of a strong opiate in a controlled manner or is it the counselling and programme structures that are the key ingredients promoting change? There is clear evidence that programmes may vary substantially in their efficacy. Programme factors include dosage of prescribed methadone, maintenance versus abstinence, and support services. Operational issues include monitoring the use of non-prescribed drugs, diversion of methadone, use of other psychoactive drugs, and oral versus injectable methadone.
Our initial attempts to "match" substance-abuse patients from an employee assistance program to an optimal setting or program failed. Scientifically, we found no differential predictors of better outcomes by setting or program. From a practical perspective, it was impossible to place patients in the intended programs. This led to a second study, designed to identify specific patient problems and match professional services to those problems within each of the 4 programs.
Ninety-four new patients admitted to 4 substance-abuse treatment programs were randomly assigned to standard treatment and treated in the usual manner or were assigned to "matched" services, in which patients received at least 3 professional sessions directed at their important employment, family, or psychiatric problems.
Matched patients stayed in treatment longer, were more likely to complete treatment, and had better posttreatment outcomes than did the standard patients treated in the same programs.
For logistical, financial, and clinical reasons, it is improbable that patients will be matched to specific types of programs. However, within any program, it is possible and practical to match appropriate services to patients' specific treatment problems. This strategy was clinically and administratively practical, attractive to patients, and responsible for a 20% to 30% increase in the effectiveness of this substance-abuse treatment system.
In An Essay concerning Human Understanding , John Locke sets out his theory of knowledge and how we acquire it. Eschewing doctrines of innate principles and ideas, Locke shows how all our ideas, even the most abstract and complex, are grounded in human experience and attained by sensation of external things or reflection upon our own mental activities. A thorough examination of the communication of ideas through language and the conventions of taking words as signs of ideas paves the way for his penetrating critique of the limitations of ideas and the extent of our knowledge of ourselves, the world, God, and morals.
Locke’s masterpiece laid the foundation of British empiricism and is of enduring interest to anyone exploring the development of philosophical thought. This sensitive abridgement uses P. H. Nidditch’s authoritative text, and together with an illuminating introduction and other features, makes Locke’s arguments more accessible.
For this collection, R. M. Hare has selected the best of his writings on medical ethics and related topics. Its chief theoretical interest lies in its synthesis between utilitarian and Kantian ethics, which are shown to have the same practical consequences. The main practical thesis in the book is that we can harm possible people by preventing them from becoming actual people. This thesis, if understood and accepted, would radically alter the terms of the public debate about embryo experimentation and population policy, and (perhaps surprisingly) support a fairly liberal view on abortion. There are also general introductions to medical and psychiatric ethics, and essays on the concept of health, the morality of experimentation on children, health care policy, free will, and vegetarianism.
The term ‘consequentialism’ refers to a class of moral theories that rank states of affairs from an impersonal standpoint and require agents to produce the best states of affairs they can. Many philosophers have criticized and rejected consequentialist theories, but Scheffler wishes to reconsider the rejection of consequentialism. He begins by discussing two objections to consequentialism, one having to do with the integrity of agents and the other with distributive justice. From there, he outlines a hybrid moral theory that avoids these two objections. Scheffler's hybrid theory agrees with consequentialism in so far as it always permits agents to produce the best states of affairs, but it departs from consequentialism by including an ‘agent‐centred prerogative’, allowing each agent to assign greater weight to his own interests than to those of others. Scheffler argues that this prerogative rests on a principled rationale—namely, that it is a rational strategy for taking into account the independence of the personal point of view. But this rationale does not support ‘agent‐centred restrictions’—norms that sometimes forbid agents from doing what would have the best outcome overall. Scheffler searches for, but does not find, a separate rationale for agent‐centred restrictions.
Drugs and drug use are an integral part of human culture. Yet we know hardly anything about drugs, at least not the kind of knowledge that would help us to understand how drugs affect people and how people beome addicted to drugs. This is most surprising in the light of the vast amount of knowledge accumulated in the sciences. Psychoanalysis might not be an obvious choice for the treatment of addiction. Nevertheless, it is in an excellent position to make a contribution to a problem that has so far defied much of our understanding. By inviting people to speak about themselves, psychoanalysis has established a unique way of collecting clinical material, a material that surely must be immediately relevant coming as it does from the horse’s mouth. With addiction on the increase, this fact alone justifies the necessity for a different approach.Providing a theoretical foundation for the argument that psychoanalysis should be seriously considered, and where possible incorporated into the treament of addicts, this thoughtful and innovative book can serve as an orientation in the ongoing front-line battle with addicts and addiction.
Sozialpsychiatrische Aspekte der Ethik — Anspruch und Wirklichkeit — sollen von mir dargestellt werden. Die Wirklichkeit, das ist der Alltag der Psychiatrie. Der Anspruch, wie wird der begründet? Läßt er sich aus philosophischen Überlegungen ableiten, aus der Anthropologie oder der Metaphysik? Hilft uns die Diskussion von ethischen Prinzipien wie Autonomie und Selbstbestimmung, Fürsorge und Unschädlichkeit? Lassen sich allgemeine Werte wie Menschenwürde und das Recht auf Selbstbestimmung im Alltag konkretisieren?
A group of 22 patients, previously addicted to diacetylmorphine (heroin), have been stabilized with oral methadone hydrochloride. This medication appears to have two useful effects: (1) relief of narcotic hunger, and (2) induction of sufficient tolerance to block the euphoric effect of an average illegal dose of diacetylmorphine. With this medication, and a comprehensive program of rehabilitation, patients have shown marked improvement; they have returned to school, obtained jobs, and have become reconciled with their families. Medical and psychometric tests have disclosed no signs of toxicity, apart from constipation. This treatment requires careful medical supervision and many social services. In our opinion, both the medication and the supporting program are essential.
Research and clinical experience reliably and repeatedly demonstrate that the determinants of health are most accurately conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. Increased appreciation of biosocial approaches have already driven change in premedical education and focused attention on population health in current U.S. health care reform. Medical education, however, places primary emphasis on biomedicine and often fails to emphasize and educate students and trainees about the social forces that shape disease and illness patterns. The authors of this Commentary argue that medical education requires a comprehensive transformation to incorporate rigorous biosocial training to ensure that all future health professionals are equipped with the knowledge and skills necessary to practice social medicine. Three distinct models for accomplishing such transformation are presented: SocMed's monthlong, elective courses in Northern Uganda and Haiti; Harvard Medical School's semester-long, required social medicine course; and the Lebanese American University's curricular integration of social medicine throughout its entire four-year curriculum. Successful implementation of social medicine training requires the institutionalization of biosocial curricula; the utilization of innovative, engaging pedagogies; and the involvement of health professions students from broad demographic backgrounds and with all career interests. The achievement of such transformational and necessary change to medical education will prepare future health practitioners working in all settings to respond more proactively and comprehensively to the health needs of all populations.
Brackets] enclose editorial explanations. Small ·dots· enclose material that has been added, but can be read as though it were part of the original text. Occasional • bullets, and also indenting of passages that are not quotations, are meant as aids to grasping the structure of a sentence or a thought. Every four-point ellipsis . . . . indicates the omission of a brief passage that seems to present more difficulty than it is worth. Longer omissions are reported on, between [brackets], in normal-sized type.
Die Opiatabhängigkeit ist eine chronische Erkrankung. Die in den westlichen Ländern am meisten verbreitete Therapie Opiatabhängiger ist die Substitutionsbehandlung. Durch die regelmäßige Einnahme eines ärztlich verschriebenen Opioides werden Entzugsbeschwerden und Heroinverlangen wirksam unterdrückt, sodass das Therapieziel Reduktion des Heroinkonsums und der damit unmittelbar verbundenen Probleme bei kontinuierlicher Substitution in der Regel erreicht wird. Darüber hinausgehende Ziele sind vor allem die Reduktion des Konsums weiterer Suchtmittel und die Linderung komorbider psychischer Störungen. Insbesondere zur Reduktion des Beigebrauchs werden unterschiedliche psychotherapeutische Strategien vorgestellt wie das Contingency Management, der Community Reinforcement Approach, die psychodynamische Fokaltherapie sowie die kognitiv-verhaltenstherapeutische Psychotherapie. Die zuletzt genannte Strategie wird anhand einer Fallgeschichte und einer eigenen Untersuchung illustriert. Entgegen einem verbreiteten therapeutischen Nihilismus gibt es evaluierte psychotherapeutische Strategien zur Behandlung Opiatabhängiger, insbesondere zur Reduktion des Beigebrauchs in Substitutionsbehandlung.
The medicinal value of opium as an analgesic has been known to humankind for centuries. In England during the nineteenth century it was regarded, especially among the labouring classes, as a popular panacea for a variety of ailments. However by the end of the century addiction emerged as an issue of public concern - due largely to the ‘moral crusade’ launched by the Victorian anti-opium movement against the non-medical use of opium. Central to the movement's campaign was a certain model of addiction, promulgated by its most prominent organisation, the Society for the Suppression of the Opium Trade. This paper examines how this model was taken as an objective reality.
Professionals across fields claim to learn much from experience. Self-study as an approach to learning about one’s work and
theories in use offers explicit methodologies, including reflective reading, transformative professional development and inquiry
to inform professional artistry. These three approaches look for patterns of beliefs and values that assist practitioners
to know themselves more authentically within the dimensions of their work. Most professions set standards for individual growth
and development that, in turn, a3ect organizational progress. Nevertheless, few, if any, consider self-study as an explicit
means for reaching personal/professional goals or gaining insight into individuals’ strengths and weaknesses. This chapter
addresses the needs of both nOffice and seasoned practitioners who continue to learn about themselves within the context of
their work. It offers both rationale and examples for learning how to examine personal motives and assumptions within the
explicit technical and implicit human expectations of the helping professions, this chapter draws on three examples the: librarian,
postsecondary teacher and, occupational therapist.
3., durchgesehene und erw. Aufl
National Addiction Centre, Institute of Psychiatry and Maudsley Hospital, London SE5 8AF National Drug and Alcohol Research Centre, University of New South Wales, Sydney NSW 2033 Centre for Research on Drugs and Health Behaviour, London SW7 1RQ Beth Israel Medical Centre, New York, NY 10003, USA Correspondence to: Dr Farrell. This paper examines the changes and advances in research and clinical practice and examines the role of treatment structure and programme characteristics in the delivery of methadone maintenance. Methadone prescribing has become much more available over the past decade, both in countries with a history of its use, such as the United Kingdom and Australia, and in countries around the world which previously had not endorsed substitute prescribing.1 There is a need to examine closely the framework in which this treatment is delivered to ensure that the modes of delivery most effective from both cost and benefit perspectives are utilised. This review focuses entirely on methadone maintenance because this is the most extensively evaluated and most used treatment, with about a quarter of a million drug misusers receiving methadone treatment globally. A small number of experimental diamorphine and buprenorphine substitute programmes are . . . [Full text of this article]
This paper makes two contributions to the modeling of addiction. First, we provide new and convincing evidence that smokers
are forward-looking in their smoking decisions, using state excise tax increases that have been legislatively enacted but
are not yet effective, and monthly data on consumption. Second, we recognize the strong evidence that preferences with respect
to smoking are time inconsistent, with individuals both not recognizing the true difficulty of quitting and searching for
self-control devices to help them quit. We develop a new model of addictive behavior that takes as its starting point the
standard “rational addiction” model, but incorporates time-inconsistent preferences. This model also exhibits forward-looking
behavior, but it has strikingly different normative implications; in this case optimal government policy should depend not
only on the externalities that smokers impose on others but also on the “internalities” imposed by smokers on themselves.
We estimate that the optimal tax per pack of cigarettes should he at least one dollar higher under our formulation than in
the rational addiction case.
The connections between sociocultural factors and alcohol dependence may be approached in several ways. Sociocultural factors can be treated as predictors and correlates extrinsic to dependence, viewed as a disease entity. The concept of dependence can be reexamined in terms of its presumed ‘seating’- in the individual's psyche or body - and expanded to include the possibility of seating at supraindividual sociocultural levels. And the idea of dependence can be reinterpreted as ‘culture-bound’, that is, as depending for its existence and meaningfulness on sociocultural characteristics specific to particular times and places. The paper focuses on the latter two approaches, with particular attention to the development of sociological ‘constructionist’ thinking that views the concept and experiential reality of addiction or dependence as a product of particular cultural conditions rather than as a transcultural universal.
Between 1972 and 1974, the outcomes of army enlisted men who had served in Vietnam during 1970-71 were evaluated and compared with that of a matched group. This paper reports the major findings of that study with respect to frequency of narcotic addiction in and after Vietnam, and the major risk factors for Vietnam addiction and later relapse. Extraordinary access to records facilitated drawing the sample, locating it, and verifying interview responses. The surprisingly low levels of readdiction and the rarity of addiction to narcotics alone as compared with poly-substance dependence are findings still not entirely incorporated into public and scientific views of heroin addiction. Some defenses against that incorporation are examined.
The cross-cultural applicability of criteria for the diagnosis of substance use disorders and of instruments used for their assessment were studied in nine cultures. The qualitative and quantitative methods used in the study are described. Equivalents for English terms and concepts were found for all instrument items, diagnostic criteria, diagnoses and concepts, although often there was no single term equivalent to the English in the languages studied. Items assuming self-consciousness about feelings, and imputing causal relations, posed difficulties in several cultures. Single equivalent terms were lacking for some diagnostic criteria, and criteria were sometimes not readily differentiated from one another. Several criteria--narrowing of the drinking repertoire, time spent obtaining and using the drug, and tolerance for the drug--were less easy to use in cultures other than the United States. Thresholds for diagnosis used by clinicians often differed. In most cultures, clinicians were more likely to make a diagnosis of drug dependence than of alcohol dependence although behavioural signs were equivalent. The attitudes of societies to alcohol and drug use affects the use of criteria and the making of diagnoses.
Scientific advances over the past 20 years have shown that drug addiction is a chronic, relapsing disease that results from
the prolonged effects of drugs on the brain. As with many other brain diseases, addiction has embedded behavioral and social-context
aspects that are important parts of the disorder itself. Therefore, the most effective treatment approaches will include biological,
behavioral, and social-context components. Recognizing addiction as a chronic, relapsing brain disorder characterized by compulsive
drug seeking and use can impact society's overall health and social policy strategies and help diminish the health and social
costs associated with drug abuse and addiction.
Of central importance is that our clinical experience and treatment outcome studies to date strongly suggest that coercion is fundamental to addiction treatment and favorable outcomes from therapeutic interventions. Often the alcoholic/drug abuser must be given an opportunity to feel, face, or experience the "consequences" of their alcohol and drug addiction before the denial of their illness can be penetrated and motivation for treatment to recover from addictive illness can be developed. Continued use of alcohol and drugs is an unhealthy and dangerous state for those who are addicted and for others who are affected by their addictive illnesses. Effective therapeutic interventions and long-term recovery are more likely to succeed if avoiding "alternative consequences" are contingent on continued compliance with addiction treatment by those who suffer from addictive illnesses.
Heroin-assisted substitution treatment for severely opioid-dependent drug users has been available in Switzerland since 1994. Our aim was to ascertain the feasibility, safety, and efficacy of this treatment.
We did a cohort study in 21 community outpatient treatment centres. We assessed 1969 opioid-dependent drug users, who began heroin-assisted substitution treatment between January, 1994, and December, 2000, to ascertain admission and discharge patterns, and patient characteristics. We also followed up a subset of 237 patients who began treatment between Jan 1, 1994, and March 31, 1995, and who stayed with the programme for at least 18 months. We used questionnaires, interviews, and medical examinations done at entry and after 6, 12, and 18 months to assess somatic and mental health, social integration, and treatment outcomes.
More than 70% (1378) of patients remained in treatment for more than a year. Treatment showed positive effects with respect to health and social outcomes. A long stay in treatment was related to a higher chance of starting abstinence-oriented therapy than a short stay.
Heroin-assisted substitution treatment might be an effective option for chronically addicted patients for whom other treatments have failed.
Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples (n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples (n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after > 3-6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.