Drug Abuse and Addiction
There are many reasons for substance abuse to develop. Once it begins, more and more aspects of life become involved in drug craving. Virtually any feeling, thought or memory may become associated with drug craving and drug use. When a severe psychological and physical addiction to opiate/opioid drugs develops, fear of withdrawal becomes the main factor maintaining drug seeking and drug use. At this point, methadone or buprenorphine maintenance treatment becomes an attractive option for the patient.
Basic Philosophy of Treatment
We believe it is important to address all issues of a client to the extent possible. Client willingness to work on these issues is critical. Areas addressed include: opiate/opioid and other substance and non-pharmacologic abuse/addiction problems; psychiatric and psychosocial (including sex/gender and spiritual/religious) issues and problems; general health issues, and chronic pain syndromes; social and vocational problems.
The initial goal of this opioid agonist treatment program is to move patients from an extremely dysfunctional pattern of psychological and physical opiate addiction and polydrug abuse to a managed opioid dependence that allows normal functioning and meaningful psychological treatment. In a later treatment phase, patients may be gradually withdrawn.
If clearly indicated, not simply on patient's request, patients may be medically withdrawn with short-term methadone or buprenorphine treatment, while being offered individual therapy, group therapy, ear acupuncture, and follow-up narcotic antagonist treatment, or they may be referred to a physician specialized in medical withdrawal, possibly using experimental approaches. If patients demand treatment that is not indicated, they are referred to other treatment centers.
In contrast to "recovering" drug users on no medication, patients in synthetic narcotic treatment programs may have lapses into substance abuse without relapse into addiction. A patient, while still physiologically dependent, can live an essentially normal life and should show little or no symptoms of addiction. This means there is little or no craving or withdrawal and the client has the ability to cope with withdrawal-like symptoms or fear of withdrawal. Patients should learn to deal with and prevent drug craving, and they are helped to develop strong, positive motivation for a drug-free, healthy life style. Relaxation, meditation, contemplation and self-hypnotic techniques are taught in groups, which are offered to all clients. Many younger patients, patients with a relatively short addiction history, and patients who functioned well in the past greatly benefit from an intensive style of treatment participation in the first few days and weeks of therapy. This helps to prevent development of a pattern of substance abuse while on methadone. The long-term goal for most patients is to accomplish slow medical withdrawal while showing no substance abuse behaviors, in addition to learning to cope with anxiety, depression, drug craving, and life stressors.
The treatment team's role is to help the patient clarify problems and goals, to show some caring while being appropriately confrontive. This is particularly important in the very early stage of treatment and during a crisis. In addition, the treatment team works to move the patient into active treatment when he/she is resistant but shows some signs of treatment readiness. Both general psychiatric and substance abuse problems are addressed in psychotherapy and in groups. Indicated psychotropic medications, mainly antidepressants, are prescribed by a psychiatrist of this clinic, unless the patient is presently treated by another psychiatrist. All additional addiction problems are addressed, particularly smoking. General health evaluations, teaching and referrals are important parts of treatment. Group approaches are preferred over individual teaching and counseling whenever possible. Significant others, including close friends, parents and older teenage children of patients, may participate in groups and other treatment. Counseling is primarily cognitive-behavioral and otherwise eclectic. Groups emphasize tertiary abuse prevention, understanding of psychological problems, dealing with stress, anxiety and mood disorders, and use of a wide range of self-help approaches. Spirituality is valued by many patients. However, it is recognized that 12-step self-help groups (AA, NA, CA, etc.) are very helpful to some, but not necessarily most, severely opiate-addicted persons. While emphasizing positive motivation and relapse prevention, we like to stress the methadone client's health rather than disease and slow recovery. Nurse-case managers often function to some degree as social workers and may make appropriate referrals for any type of problem.
Abuse behaviors are positively motivated (essentially pleasure-seeking) and often performed wholeheartedly, with little internal conflict at the time. This occurs despite the possible awareness of the individual that the behavior is in some way "bad". "Bad" may be defined as behavior that goes against the prevailing culture, is harmful to others, or is unhealthy to self, etc. The primary purpose of abuse behavior is to feel good or at least better. The abuser appears to exercise some control; i.e., abuse behaviors stand side by side with other positively perceived behavior options. If there is a special reason not to abuse, an individual will usually abstain. In other words, there are other choices the abuser perceives as comparably good.
Addiction is an essentially normal psychological response to exposure to abusable drugs "at the wrong time" with consequent increasing abuse. Addiciton develops when there are no protective factors; that is, when the person has no strong reason to refrain from the attractive abuse behavior. Addiction is not "compulsive." It is a pleasure-seeking (positively motivated) behavior pattern that dominates much of the addict's life and is continued despite negative consequences. To the addict, pleasure and avoidance of temporary withdrawal are more important than the negative effects of the abuse pattern. In addiction, the abuse behavior appears to have become a first priority. Addiction is often defined in terms of frequency of behavior. However, the severity of preoccupation is probably more important than actual frequency of use. There are often positively perceived, pleasurable obsessions individuals have, only their frustration and/or moral conflicts act as deterrents. Addiction is a learned, disordered-thought behavior pattern -- a core disturbance of the emotional-behavioral system. Addiction is not a disease in that it does not damage tissue. Normal behavior patterns still exist, are intact, and can be utilized when abuse/addiction behaviors stop; for example when treatment starts or when the patient finds powerful, positive motivation that acts as a deterrent.
Compulsions serve to avoid an irrationally feared occurrence. Insight is not helpful in stopping them. Compulsions are negatively motivated and ego-dystonic; i.e., they do not feel good. They are often performed repeatedly with only gradual or partial relief. Compulsivity usually includes negative obsessions with mental rituals occurring frequently.
Physical habits, such as nail biting, hair pulling, or skin picking, may represent exaggerated primitive inborn behaviors ("reptilian", "over-grooming behaviors"). Their frequency often increases with anxiety but seem automatic with little associated emotion. They do not relieve anxiety.
Habits are basically neutral -- not 'good' or 'bad'. Positive habits are often "compulsively" adhered to because the individual fears getting out of routine and losing benefits. Positive and neutral habits may be valued as part of the individual's personality. Damaging and destructive habits are generally part of psychopathology and/or abuse-addiction patterns.
Positive and non-damaging, neutral pleasurable habits are not addictions. For example, masturbation is an addiction if regularly pursued in spite of a belief that it is wrong or damaging, otherwise it is, generally, a neutral pleasurable habit.
Misuse refers to inappropriate use. Examples include self-medicating with a medication prescribed for another condition, and the use of alcohol or illicit drugs as psychotropic medications for psychiatric disorders.
Cultural use includes regular and structured use of alcohol and other drugs within specific contexts prescribed by the culture. In cultural use, the drug is not used for self-medication or as a form of pleasure-seeking. Cultures may encourage "acting out" and pleasure seeking behaviors during a specific festival or rite. For some people, such cultural drug use may lead to abuse and addiction patterns. Generally, the more structured a behavior is, the safer it is.
Dependence generally refers to a physiological adaptation to a drug, with tolerance and withdrawal occurring on discontinuation. In contrast, psychological addiction generally refers to regular abuse. Many non-abusable drugs lead to dependence, e.g. Aspirin and blood pressure medications, and many people are dependent on abusable drugs without being addicted. Examples include tranquilizer use for treatment of diagnosed anxiety disorders, or opiate pain medication use during prolonged treatment of major burns.
Non-pharmacological abuse and addiction patterns are frequent. Examples include gambling, consumption addiction, "perversions" (inappropriate ways of instinct fulfillment which are in some way damaging and used to relieve boredom and stress or for pleasure) (e.g., addictions to aberrant aggressive, sexual or eating behaviors). Money, representing most forms of instinct fulfillment, can be addicting. Sometimes dynamics are unclear: "workaholics" may possibly be avoiding family or addicted to material wealth rather than addicted to work.