Treating Drug Abusers

G Bennett

• Publisher: Routledge
• Year: 2004
• Print ISBN: 9781138400955
• eBook ISBN: 9781134931736
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Treating Drug Abusers provides a clear, practical guide to current approaches in the treatment of drug-taking. Written by practitioners for practitioners, it takes a psychological perspective to the problem. The authors include detailed case studies of particular treatments, focusing on, among other things, relapse and its prevention, family therapy, and the transmission of the HIV virus.

Chapter One
Introduction

Gerald Bennett

This book has been written for those attempting to help drug users, with the practical aim of aiding them to improve their work with individuals and to develop their services. It has been written by drug workers and is based largely on what they have learned from their clinical experience, together with theory and research findings which have proved helpful. The practical aim shows itself in the detailed, often prescriptive, accounts written about therapeutic approaches; much of this work makes little reference to research findings which can validate or guide the tasks which drug services face—this is because such research has never been carried out. One of the chapters is exceptional in reporting the first findings of a scientific evaluation of one particular therapeutic approach, but for the most part practice has gone beyond research, and is guided by an amalgam of experience and theory.

Several important themes run through the contents of this book. Two of these, which are central concerns of Tober’s contribution (Chapter 2), are the importance of learning, and the developing nature of motivation. Others are the roles of pharmacological treatments and the potential for new drug services to learn from elsewhere, principally alcohol agencies and drug agencies in the past.

The importance of learning

Drug users learn to use drugs through processes which are not unique to them, but are common to most areas of life; these operate in the individual in their own unique set of circumstances. In Chapter 2 Tober describes some of the ways in which learning processes can be involved when people learn to take drugs in different ways, including dependent use, and the factors involved in maintaining these habits. This perspective explains that people continue to take drugs, not because they have an illness or are totally irrational, but because this activity has short-term advantages for them which outweigh the long-term disadvantages. The potential gains that may even occur for the families of drug users are explored in the chapter on family perspectives and family therapy by Yandoli and his colleagues (Chapter 4). The importance of learning is also relevant for drug users when they wish to stop taking drugs. They may need to develop alternative means of achieving some of the benefits that drug taking brings them, or of developing skills to better cope with areas of life that are problematic and may increase their vulnerability to the attractions of drugs. Such skills might, for example, aid them to achieve independence from their parents or to cope with symptoms of anxiety. In their chapter on AIDS Dickson and Hollis argue strongly that developing attractive alternative skills is crucial where change in sexual practices is advocated. There may also be value in unlearning ingrained responses to certain situations, such as the automatic craving that may accompany handling syringes.

The process of learning is seldom error-free, and there is little reason to expect that drug users who are learning to live without drugs should be able to achieve this successfully at the first attempt. As Scott points out in his chapter on relapse prevention training (Chapter 5) drug services have not always absorbed the implications of the notion that mistakes are important learning experiences, and the fact that most people who do become lastingly drug free do so as a result of a stuttering series of unsuccessful attempts. Scott’s contribution describes therapeutic approaches to facilitate this process.

The developing nature of motivation

This book represents a move away from the over-simple view of drug users as being either motivated or not-motivated to stop using drugs (with the implication that only motivated users can be helped). Most chapters refer to the stages of change model of Prochaska and DiClemente (1984) which argues that drug users who stop, go through a predictable sequence of different stages in which their motivation develops and changes. This view has had a practical implication of pointing out the differing needs of people in different stages of change, so that comprehensive services should serve each appropriately; the injecting drug user who is determined to continue taking drugs, the user who is thinking of stopping, the person who is actively trying to stop, and the person who has been stopped for some time. Dickson and Hollis (Chapter 8) describe some of the practical ways in which determined drug users can be helped to protect themselves from the potentially fatal HIV infection. If the nature of motivation can develop and change in predictable ways, then there is a potential for stimulating this process. One attempt to do this is presented by van Bilsen and van Emst (in Chapter 3) in their development of ‘motivational interviewing’ techniques, for use in working with heroin users who are considering the possibility of change. This is concerned with the skills required to engage clients, and to encourage them to return again, because services which don’t see clients cannot influence them. Most chapters address this issue of engaging potential customers, and the implications of this for the organisation of services. Hamlin and Hammersley (in Chapter 7) describe the importance of first contacts with benzodiazepine users, and ways of handling these so as to maximise the possibility of engaging them in treatment. The chapter on family therapy describes ways of drawing partners and parents into this demanding treatment approach. Understanding the varying and fluctuating nature of motivation has implications for engaging and working with a wider group of drug users.

The roles of medication

Only one chapter focuses exclusively on medical treatments, but every other contribution discusses them. Pharmacological treatments fulfil a variety of functions and most treatment approaches require an integration of medical and non-medical components. Prescribing drugs can attract opiate users into contact with services so as to facilitate many of the treatments described in this book. It can help drug takers move away from injection. Users dependent on opiates can often be helped to withdraw humanely through the detoxification procedures described in detail by Choudry (in Chapter 6), just as those dependent on benzodiazepines can be helped by the prescribing strategies recommended by Hamlin and Hammersley. Helping opiate users gain access to these treatments can be a frustrating task for non-prescribing services; in Chapter 10 there is a clear description of the frustrations felt by Community Drug Teams (CDTs) working with GPs whose guidelines of practice with this group is to ‘just say no’. Another area of frustration for non-prescribers lies in the primacy accorded to ‘the script’ by drug users, elevating it in importance to a much higher status than the personal changes that psychological procedures attempt to bring about. Ways of avoiding these conflicts include the combination of family therapy with a non-negotiable methadone regime, and low threshold prescribing programmes which facilitate constructive contact (van Bilsen and van Emst’s ‘motivational milieu therapy’). Some non-prescribing Community Drug Teams described by Schneider, et al. (in Chapter 10) have found it necessary to integrate their work with that of prescribers. The argument for integrated medical and non-medical help also comes from findings that the intensity of the opiate withdrawal syndrome is strongly affected by such psychological factors as emotionality and anxiety levels, and can be alleviated by presenting accurate information about the time course of the syndrome (Phillips, Gossop, and Bradley 1986; Green and Gossop 1988).

The potential for drug services to learn from elsewhere

Many of the current discussions about drug services are being conducted as if they were completely unique. During 1987 controversies about prescribing practice became widespread (as evidenced by a series of articles in Druglink), debating the value of maintenance prescribing. As Wilks argues in her discussion of these issues (in Chapter 9), these arguments have generally not been informed by a critical appreciation of evidence from the past. Arguments for and against, for example, the prescription of injectable heroin, have made little reference to this country’s experience of carrying out such a policy in the past. Strong arguments for maintenance prescribing in Britain today have been proposed using historical evidence from other countries. For example, Marks (1987) cites Vaillant’s (1973) work to argue for a ten-year natural span for heroin addiction—making the questionable assumption that this work is directly relevant to drug use in Britain today, based as it is on the experience of New York addicts detoxified in hospital in Kentucky in 1953. Services can learn from a critical reading of the past, and also from the experiences of other services. Clement argues in her review of issues arising in other community teams, particularly Community Alcohol Teams (CATs), that few of the dilemmas faced by CDTs are entirely new (Chapter 11). In many districts CDTs are the very first service for drug takers and have responded to novel problems in creative ways (see Chapter 10). Yet many of their management and policy issues have been already faced by CATs and Community Mental Handicap Teams, and ignoring the lessons learned there may prove foolhardy.

These four issues reflect changes and developments in attempts to respond to the problems of drug users, when, in the era of AIDS, the philosophy and practice of services need to be reconsidered in order to reach and serve a wider population.

© 1989 Gerald Bennett

References

Green, L. and Gossop, M. (1988) ‘Effects of information on the opiate withdrawal syndrome’, British Journal of Addiction 83:305–9.

Marks, J. (1987) ‘State rationed drugs’, Druglink 2 (4): 14.

Phillips, G.T., Gossop, M., and Bradley, B. (1986) ‘The influence of psychological factors on the opiate withdrawal syndrome’, British Journal of Psychiatry 149:235–8.

Prochaska, J.O. and DiClemente, C.C. (1984) The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy, Homewood, Ill.: Dow-Jones-Irwin.

Vaillant, G.E. (1973) ‘A twenty year follow-up of New York narcotic addicts’, Archives of General Psychiatry 29:237–41.

Part One
Developments in Views of Drug Abuse

Chapter Two
Changing conceptions of the nature of drug abuse

Gillian Tober

The drug-taker’s tale

PJ is 21. She has just finished making a television documentary on ‘heroin addiction’. Her mother, who organises a support group for the parents of drug addicts, persuaded her to do it. All it involved was telling her story—her past, her present, and how she saw the future. She remembered her childhood quite well; her mother was often away from home or intoxicated at home when she was quite small; she had a slightly older sister whom she seemed to follow through life. PJ remembers first going to school, a year after her sister had started, remembers feeling so shy and frightened of the other children she would hide under the coats in the cloakroom. She remembers her sister always being good at things—school, music, sports—she remembers wanting to be special or clever at something. Most of her school years were uncomfortable—she never seemed to know how to make friends or be friends with other people.

At the age of 13 she began listening to rock’n’roll music and then going to concerts. One day some older children from school recognised her at a concert and invited her to join them. They were smoking cannabis and offered her some. She accepted, mainly because it was what they were doing and she was flattered to be asked to join them. She enjoyed the effect of the cannabis—because it made the music sound better and made her feel more relaxed about being younger than the others. It made her feel grown-up.

From then on PJ looked out for the same group of youngsters at concerts and regularly joined them, smoked cannabis with them and had a good time. After a few months she was at a concert where her friends knew the boys in the band; they all went off to a party afterwards and PJ was invited along. At the party there were drugs other than cannabis—some white powder people were snorting off mirrors through twenty pound notes. PJ was intrigued; when offered some she immediately agreed and liked the effect. Again it made her feel confident and she chatted easily with the boys in the band. They invited her to come with them to see their concert.

Meanwhile at home and at school all was not well. PJ had started to buy her own supplies of cannabis because she reckoned she could do with feeling good—feeling warm and confident on more occasions than just at concerts. Also she did not want to be reliant on other people for supplies of cannabis but wanted to make a contribution herself. She had started to smoke cannabis at home in her room and her mother had ‘caught’ her at it. Feeling very guilty about an alcohol problem she once had, her mother tried to talk to PJ about the possible dangers of drug taking—rather than telling her off about it. But for PJ—if this was dangerous then she would put up with the risks. She was having a great time, she had friends, she was accepted. At school, rather than just being shy and isolated, she now had a secret world she could dream about. When they told her not to come to school with purple make-up and a ring in her nostril she felt secretly proud. Before she had only felt embarrassed when she was told off for the way she looked—her uncombed hair or dirty fingernails. She was embarrassed because it drew attention to her elf-like figure.

The more PJ took drugs at parties and concerts, the more the days in between seemed bleak and empty, and the more she wanted to improve them by having her own supplies. She would rush home from school to smoke some cannabis and thereafter have a pleasant evening. PJ’s mother was getting increasingly worried about PJ’s drug taking and confided in the family doctor, who subsequently had a talk with PJ. He told her she would have to become a ‘common whore’ to support her drug taking—and she may well become one anyway if she hung around with rock’n’roll bands. This was not how PJ saw herself.

Becoming increasingly alienated from family, school and other people in positions of authority, PJ sought out her drug-taking friends more and more for comfort, affirmation and affection. When she was eventually introduced to heroin she reckoned she had discovered the drug that satisfied her need for all those things—all she had to do was get hold of it.

PJ was 17 when first she was offered heroin. She had tried most other drugs, amphetamine, cocaine, cannabis, LSD and barbiturates. The only drug she had felt inclined to take regularly was cannabis. It had a reliably comforting effect even if it did occasionally seem to cause some anxiety and morbid fantasies. But heroin was different from anything else. She just felt good, without the anxiety and paranoia. She preferred it to the other drugs. Moreover, if she injected it (and injecting drugs was not new to her as she had done this with amphetamine and barbiturates) she would get a sensation to begin with that made her feel completely wonderful. The others told her that sex was like this. With heroin she would never have to let anyone look at her body, or so she thought then.

‘For there is nothing good or bad but thinking makes it so’

PJ has learned to take drugs. Her early drug taking was a response to internal triggers (the desire to be accepted by a particular group of people), and external triggers (the drug-taking habits of that particular group of people). The consequences of her drug taking were, as she perceived them, that she came to be accepted by that group of people, and additionally, that she enjoyed the effects of the drugs. She felt more relaxed, less self-conscious, and subsequently warm and loved, these positive consequences encouraged her to continue to take drugs. The expectation of relaxation and acceptance came to operate as triggers or cues for drug taking at particular times of the day and week, in other words—the consequences of the drug taking became cues for drug taking—when PJ felt to be in need of relaxation and/or social contact. Certainly there were some negative consequences like trouble with the family and family doctor and difficulties at school, but these negative consequences were less important to her and they were also less immediate.

This process of learning a behaviour by the consequences of that behaviour is called operant conditioning or instrumental learning. It is described fully in relation to problem drinking by Heather and Robertson (1985), and it is quite easy to see the parallels with drug taking.

The important fe...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Chapter One: Introduction
• Part One: Developments In Views of Drug Abuse
• Part Two: Developments In Treatment
• Part Three: Developments In Services