Because addiction has no solitary cause, the new view toward it
demands that single-minded approaches to drug treatment be abandoned. At
least four studies, according to William Miller, have found no
differences between groups of alcoholics assigned to Alcoholics Anonymous
and to no treatment at all. AA simply doesn't work for a lot of people.
Consistently negative findings have also come from controlled studies of
in-sight-oriented psychotherapies, antipsychotic drugs, confrontational
counseling, most forms of aversion therapy, educational lectures, group
therapy, psychedelics, and hospitalization.
"A rather remarkable amount of research has been conducted on the
effectiveness of several dozen approaches to the treatment of substance
abuse," says New Mexico's Miller. But sadly, he says, the chug treatment
community has been curiously resistant to using what works. His
colleague, Reed Hester, after a review of treatment outcomes from 1980 to
1990, concluded that "despite much more knowledge of what works,
treatment for substance abuse hasn't changed much in 40 years."
Plenty of things, however, do appear to work--some simple, some
complicated, and some novel. Some samples:
Brief intervention. According to Miller, studies show conclusively
that very brief treatment, if designed properly, is highly successful
against even moderately severe addictions.
"We found this out the hard way," he recalls. In 1976, in one of
his studies of controlled drinking, Miller separated his subjects into
two groups. The treatment group got a variety of treatments, including
counseling and disulfiram (Antabuse). The control group was given only a
brief self-help manual and told to go home, read it, and do their
best.
"To our amazement, people in the control group did just as well as
the treatment group. We thought we had really messed up the study so we
repeated it twice again and got the same results.
"Then we went looking for what was really happening. We gave one
group the manual and another group no manual. The manual turned out to be
the variable that was the potent treatment. But why? We knew it wasn't
the effect of our initial interview with the subjects, or some difference
in the patient groups.
"The key was that we had inadvertently motivated the control group
and in spite of our expectations, the addicts changed and moderated their
drinking. Simply giving them the manual, saying to them that we believed
they could help themselves, could handle it, you can do this, was
enough."
Since then, Miller and other therapists have refined and modified
"motivational interviewing" and brief-intervention therapy. More than 30
studies in 14 countries have affirmed the value of its key components,
dubbed FRAMES: Feedback--specific and tailored to the individual, not
general; Responsibility--it's up to you, your choice, you are not a
helpless victim of a disease; Advice--firm and clear recommendations;
Menu--there are different ways to work this out; Empathy--the best
therapists have this and are neither pushy nor confrontational, but
supportive and warm; and Self-efficacy--you can do it;
empowerment.
"Warm turkey." Tapering down and "sobriety sampling" give addicts a
chance to kick their habits and help them not give up if they
fail.
In the hands of trained therapists, this and other forms of
"relapse prevention" teaches addicts skills for coping with mistakes and
setbacks. These methods also allow for moderate continuation of some
addictions for some people, rather than insisting on total
abstinence.
Pharmacologic treatment. Drug treatments for addictions have
historically been the least successful and the least available. Except
for methadone (which many experts feel largely failed because
accompanying social services and counseling were not given to addicts)
and Antabuse for alcoholics, there has not been much to offer.
However, several groups of scientists are conducting studies
looking for a methadone-style treatment for cocaine addiction. Now that
neurobiologists and neurochemists have pinpointed those parts of the
brain and the neurotransmitter system where cocaine exerts its effect,
they plan to develop drugs that block it.
As Childers explains: "Cocaine activates dopamine by inhibiting a
mechanism that pushes dopamine back into nerve endings that release it.
This pump, known as a dopamine transporter protein, is so inhibited by
cocaine that dopamine is released in relatively huge amounts."
In the past 18 months, George Uhl, M.D., Ph.D., of the NIDA
Addiction Research Center, and other scientists, using the gene cloned
for the dopamine transporter protein, located specific areas where
dopamine and cocaine both act in the brain.
Childers says the goal is to develop "designer drugs," man-made
molecules that can block cocaine receptors without shutting down the
dopamine transport system. (These are known as "antagonists" because they
block the receptors.) Another strategy is to develop drugs that bind
lightly to cocaine receptors, producing a very mild form of cocaine
"rush" but also blocking cocaine itself. These drugs are known as mixed
agonist/antagonists, or long-acting agonists.
Tags:
alcoholics,
amazement,
antabuse,
antipsychotic drugs,
control group,
drug addiction,
drug treatment,
hospitalization,
intervention,
natural medicine,
negative findings,
psychedelics,
therapy,
treatment group,
william miller
