European Working Group on Drugs Oriented Research Conference: One size does not fit all

“We all need something to help us unwind at the end of the day. You might have a glass of wine, or a joint, or a big delicious blob of heroin, to silence your silly brainbox of its witterings, but there has to be some form of punctuation, or life just seems utterly relentless.”

― Russell Brand, My Booky Wook 
The 15thInternational EWODOR Symposium, on May 22-23, 2014, was hosted by Coolmine therapeutic community (T.C.) at Trinity College Dublin, Ireland. The conference was capped to 100 attendees, 20 more than usual. This post brings a flavour of four key notes (out of 14).

Irish Addiction Treatment vs MacDonald’s

Was Coolmine TC like McDonald’s? Did it stifle it’s openness to change? Did it hinder adaptation to change? 

Through archival sources, meetings, correspondence, interviews with clients, current and former staff, past staff, Prof Butler researched sociological history of the first therapeutic community in Ireland – the Coolmine. The driving force behind Coolmine was Paddy Rossmore who had 2 recovering users from UK to start Coolmine. A complete reordering of Coolmine happened when Sam Anglin from Daytop, New York rejigged Coolmine, quite like a cult. No one opposed it openly – How do you like if your students were critical with you? But the question is “Was it the Daytop-isation or MacDonalds-isation?”
Sociologist, George Ritzer coined the fast food metaphor which has been researched for the past 20 years. It has been used for many problems since then. “Eat it and beat it” philosophy captures the main dimensions of MacDonaldisation – efficiency, calculability, predictability and control. Is this system dehumanising? To answer this question, we would have to answer a bigger question “Are people predictable, controllable, efficient and calculable?” No, but the answers divide helping professionals into 2 camps: one which clearly says “No”, and the second that says “No, but some behaviours can be predicted, controlled, calculated and changed.” Similar to the dichotomy of the left and right side of brain,  the true answer lies probably somewhere in the middle. No one wants to eat like McDonald’s, but addiction treatment can learn a lot from its business model.
What Prof Butler’s presentation showed us was that sticking rigidly to a foreign TC model may be worse than adapting flexibly to changes in society. Universal approach – one-size-fits-all – does not fit the addiction treatment. His presentation, however, did not answer the Gawande’s question modified for the drugs field: “Food chains have managed to combine quality control, cost control, and innovation. Can addiction treatment?” 
 

L-R: Butler, Yates and Pearce

Drug relationships: I love you and heroin

What is a drug relationship? 

DrMayock answered this question through narratives and interviews with women – drug users. It’s a struggle – Suffering on one hand and intimacy on the other hand. Exchange, power and control are the key characters in such relationship. Half of the interviewed women started using drugs in the relationship. Women were often reliant on the partner to administer heroin. They used threats and rewards – leave temporarily or sex for drugs and protection. Women in drugs economies played a supportive role. However, drugs were not the only connection between partners: “but I love him”, said one of the interviewees. Significance of the relationship beyond drugs was clear even after the end of the relationship. What is the true identity of a female drug user – an abused victim or a tender lover? They are both true.

There’s too much morals around women’s drug use, creating stigma and dismissal. Simmons writes that we need a more complex and nuanced understanding of drug-using couples – “drug treatment providers should:
  • establish policies which recognize the existence and importance of interpersonal dynamics between drug users, and
  • work with them to coordinate detoxification and treatment for both partners, and
  • provide additional integrated couples-oriented services”(Simmons& Singer, 2006).  

Can we do clinical trials of TCs? Or why there is a lack of robust evidence on TCs

What is a TC? What are the critical components and active ingredients?

On a practical level, Dr Pearce summarised the scientific literature on TCs. Therapeutic communities are a popular treatment for the rehabilitation of drug users. This Cochrane systematic review showed that “there is little evidence that TCs offer significant benefits in comparison with other residential treatment, or that one type of TC is better than another”, while another review concluded that “TCs can promote change regarding various outcome categories”. The critics of the Cochrane review for only including randomized trials, “while random group allocation appeared to be either not feasible (i.e., significantly higher drop-out among controls), or advisable (i.e., motivation and self-selection are considered to be crucial ingredients of the treatment process), in several studies.”
Pearce’s TACIT trial, unlike many other TCs, studies a day (outpatient) TC for personality disorders in Britain. Its Primary outcome measure is the Number of days in outpatient psychiatric treatment – total hospital days. TACIT faced typical technical problems: you can’t blind people; you can’t conceal people, difficult to standardize the treatment. Blinding is an issue for all psychosocial treatments. There’s a lack of standardisation and quality control in TCs. The staff is not bothered about clinical trials – they really believe in what they are doing. The TC is a complex intervention – all of the technical problems were taken from, and addressed in, the MRC framework, same like diabetes management or parenting. The logical positivist approach is embedded in the RCT approach – control is central. However, TC can be seen as a safe container for other therapeutic interventions. To respect the principles of safety and deep consent, TACIT asked the TCs themselves whether they want to opt out from the study – none of them did so. Inadequate treatment standardisation can be overcome by using a Model for adherence – Community of Communities – peer-opinion-based accreditation. All in all, it’s possible to do it [RCT] and we should do it.
Opposing the RCT evaluations, Dr Yates argued that we know TCs work, “we’ve done them for 50 years and we know it”. The time is now to study how they work and what the basic principles are. Study TCs for new groups: young runaways, trafficked women and children, self-harmers, recidivist, asylum-seekers, survivors of child abuse, etc. In seeing TCs as learning environments – we could use that stuff in other “schools” for other “students”. For better learning, he helped to setup a Drugslibrary.stir.ac.uk.

On a more fundamental level, Dr Yates asserted that TC is one of the few interventions that systematically address all of the components of Zinberg’s “drug, set and setting” model. The main principles: community as method and whole person disorder. Retention in TCs is poor, but that’s the same for all chronic diseases – you find very poor retention, same as addiction treatment. An audience questioned TC as a very safe environment for recovery – does that necessitate residential? It requires level of intensity: You can’t fund a 6 month programme and expect 12 months outcomes.

Cited work:
Gawande, A. (2013) Big Med. New Yorker, August 13th
Smith LA, Gates S, Foxcroft D. Therapeutic communities for substance related disorder. Cochrane Database of Systematic Reviews 2006, Issue 1. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005338.pub2/full
Wouter Vanderplasschen, Kathy Colpaert, Mieke Autrique, et al., “Therapeutic Communities for Addictions: A Review of Their Effectiveness from a Recovery-Oriented Perspective,” The Scientific World Journal, vol. 2013, Article ID 427817 
Simmons, J., & Singer, M. (2006). I love you… and heroin: care and collusion among drug-using couples. Substance abuse treatment, prevention, and policy, 1, 7. doi: 1747-597X-1-7 
Zinberg, N. E. (1986). Drug, Set and Setting: The Basis for Controlled Intoxicant Use. New Haven, CT: Yale University Press.