Category: Therapeutic community

Alcohol holding up methadone treatment

This review asked whether excessive drinking can get in the way of treating heroin addiction.

No current evidence supports the clinical requirement asking people to stop their medicines for opioid addiction if they want to enter alcohol treatment.

Although there is a lot of research behind effective strategies for the screening, diagnosis and management of an alcohol or opioid use disorder individually, less is known about how best to care for those who also use other drugs, especially since the usual treatments for opioid addiction may not be allowed in a setting of alcohol use treatment.

For example, some fellowship meetings discourage people from continuing their medication for opioid addiction (methadone).  Or some residential treatment centres require people to be “drug free” upon enrolment, which includes not using their suboxone. For safety reasons, methadone clinics reduce the dose for patients who drink excessively.

This review summarizes existing research and characterizes the prevalence, clinical implications and management options for heavy drinking among people who also use other illicit drugs.

Drinking by people using agonist medications like methadone or suboxone for opioid use disorders is common and brings along many unwanted side effects. Over time, people die.

We don’t know how to treat people who have alcohol use disorder and who also use other drugs but asking them to come off their prescribed medications isn’t based on evidence.

Nolan, S., Klimas, J., & Wood, E. (2016). Alcohol use in opioid agonist treatment. Addiction Science & Clinical Practice11, 17.

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

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.
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.

Vztahy a drogy pred liecbou v recosializacii / What clients in therapeutic communities think about their past relationships

This blog post is in Slovakian*. For English version click here.

Na úvod

Na úvod by sme chceli poďakovať všetkým klientom a klientkám z resocializácie, ktorých výpovede boli použité v tomto článku a tiež personálu resocializačného strediska, ktorí nám láskavo umožnili rozprávať sa s klientmi/-tkami.
Predstavy o sociálnom fungovaní aktívnych užívateľov/-iek drog (UD) sú často sprevádzané stereotypmi a predsudkami, ktoré stigmatizácii UD. Tradičný, moralizujúci prístup na základe týchto stereotypných predstáv považuje všetky vzťahy UD za dysfunkčné a utilitárne. Na menej stigmatizujúci prístup je potrebné kvalitné porozumenie vzťahom počas užívania drog. Takýto realistickejší pohľad musí brať do úvahy: a. heterogenitu, ktorá existuje vo vzťahoch UD (typ a kvalita vzťahu), b. dôvody, prečo sú tieto vzťahy cenné a hodnotné pre všetkých UD, ktorí/-é sa v nich angažujú (okrem materiálnych dôvodov)1.  
Preto sme sa v nasledujúcom článku, spolu s klientmi/-tkami nemenovaného resocializačného strediska (RS), poobhliadli za ich vzťahmi pred liečbou v resocializácii. Našim cieľom bolo zamerať sa na dynamickú interakciu medzi užívaním drog, závislosťou a vzťahovým fungovaním u užívateľov/-iek drog (UD). Ich výpovede sme nahrávali na diktafón počas osobných rozhovorov a neskôr dôkladne analyzovali kvalitatívnym spôsobom pomocou tzv. „deskriptívno-interpretatívnej analýzy“, t.j. psychologickej metódy na spracovanie nahrávok osobných výpovedí2.
Skôr než začneme hovoriť o ich vzťahoch pred resocializáciou, priblížime priebeh rozhovorov s klientmi/-tkami. Pred každým rozhovorom sme účastníkov/-čky informovali o priebehu rozhovoru a ubezpečili ich, že účasť je dobrovoľná a anonymná. Do pilotných rozhovorov bolo zapojených celkovo päť účastníkov/-čiek s priemerným vekom 27,8 rokov, u ktorých dĺžka pobytu v resocializácii bola 2-6 mesiacov. Takmer všetci mali problémy s viacerými návykovými látkami (Pervitín, heroín, alkohol atď.). V rozhovoroch sme položili klientom/-tkám z resocializácie tieto tri základné otázky:
„Aké boli tvoje vzťahy s ostatnými ľuďmi predtým než si začal/-a brať? Čo sa dialo v tvojich vzťahoch počas užívania drog a závislosti? Akú úlohu v nich zohrávali drogy?“

Vzťahy a drogy

Nasledujúce výsledky boli vytvorené na základe výrokov klientov/-tiek a vyjadrujú spätný pohľad klientov/ klientiek na vzťahové procesy pred liečbou (resocializáciou). V tomto článku uvádzame iba niektoré zo zmien, o ktorých klienti/-tky v našom výskume hovorili. Rozsah tohto článku bohužiaľ neumožňuje popísať všetko čo klienti/ klientky uviedli, vybrali sme len najpočetnejšie a podľa nás najdôležitejšie vzťahové zmeny. Pre lepšiu názornosť sú výsledky analýzy rozdelené do dvoch období: (1) pred začiatkom užívania drog a (2) počas aktívneho užívania drog a závislosti (viď zoznam nižšie).
Vzťahy pred začiatkom užívania drog:
1. K mal pretrvávajúci až výlučný vzťah s rodinným príslušníkom (mama, sestra, babka)
2. K vníma vzťahy s rovesníkmi, v práci ako bezproblémové
3. Kolektív rovesníkov je priestorom pre experimentovanie s mäkkými drogami
Vzťahy užívateľov/-iek drog (UD) počas aktívneho užívania drog a závislosti:
4. K hodnotí vzťahy počas užívania drog ako neúprimné voči rodine a priateľom/-kám.
5. K rodina a kamaráti podporujú, motivujú k liečbe.
6. K „nerieši“ vzťahy počas užívania drog, t.j. nezaoberá sa nimi, ani nie sú prioritou.
7. Zmena okruhu kamarátov vytvára prostredie pre užívanie drog a relapsy.
Pozn. K= klient/-ka. Pre obmedzený priestor uvádzame len zmeny, o ktorých vypovedali aspoň 4 klienti/-tky.
V prvom období, t.j. pred začiatkom užívania drog, klienti/-tky opisovali celkové vzťahové nastavenie v rodine ako aj vzťahy s jednotlivými členmi rodiny a rovesníkmi/-čkami. Klient/-ka mal/a blízky až výlučný vzťah s rodinným príslušníkom/-čkou (napr. mama, sestra, babka), ktorý pretrval až do súčasnosti:
„starká bola vždycky nejaký môj azyl, to je to, bolo tak, že keď bolo neviem ako zle, tak som vždycky došla k starkej, jak mi bolo zle, tak som išla k nej“.
Účastníci/-čky vnímali svoje vzťahy s rovesníkmi/-čkami v škole a neskôr aj v práci ako bezproblémové:
„V rodine vzťahy super, s mamou, s otcom dobré vzťahy dodnes. V škole tiež normálne, priemerný prospech“.
Kolektív rovesníkov/-čok bol pre viacerých priestorom pre experimentovanie s mäkkými drogami:
„ja som bol s ňou a s jej kamarátmi a s tými kamarátmi som bol až do konca. S nimi to začalo a nejaký čas som chodil stále len s nimi, potom som naučil ja svojich kamarátov v mojom veku“.
V druhom období sa striedali fázy aktívneho užívania, návyku a pokusov o liečbu závislosti. Toto striedanie bolo prítomné aj v priateľských/ kamarátskych vzťahoch a najlepšie by sa dalo opísať ako oscilácia, či fluktuácia medzi svetom „normálnych“ ľudí a svetom „feťákov“ (podľa slov účastníkov/-čok):
„Potom som už prestal aj medzi nich chodiť, chodil som medzi úplne iných ľudí, čo mne vyhovovali, ktorí niečo brali“
Vzťahy s rodinou alebo s kamarátmi/-tkami hodnotili niektorí klienti/-tky s odstupom času ako neúprimné, pretože im nehovorili o svojom užívaní drog:
„to je inak strašné, jak som bola neúprimná, lebo ona mi hovorila, pýtala sa ma, že aké to bolo, jak som s tým dokázala prestať, ako som sa cítila a pritom som bola v období, kedy som zase brala tie drogy“.
Hlavnou témou tohto premenlivého obdobia boli zmeny v pozícii vzťahov na rebríčku priorít užívateľa/-ky drog (UD), kedy dochádzalo k tzv. re-prioritizácii. Účastníci/ -čky to opisovali ako „neriešenie“ vzťahov počas aktívneho užívania drog, ako otázku priorít a preferencie zaobstarávania drog. Miesto vzťahov na rebríčku priorít UD sa často mení, dochádza k re-prioritizácii, inými slovami čas/ energia venovaná zaobstaraniu drog je nevyhnutne bariérou pre vytváranie/ udržiavanie vzťahov:
„Proste som tie vzťahy neriešil, možno že som mal rodinu, lebo som bol naučený tak, že rodine môžeš veriť, tá ti môže jediná pomôcť, ale inak tie vzťahy, mal som zopár priateľov z ktorejkoľvek časti spoločnosti“
A práve rodina zohrávala dôležitú úlohu pri klientovej motivácii liečiť sa:
„Prišla na mňa kríza, tak mamka sa o mňa starala 3 dni, som tam krízoval, zvracal. Ten terapeut prišiel, lebo on bol na Vianoce tiež doma, on to sľúbil, tak sem zavolal, že príde, vybavil to tu a išiel som. Mamka sa pýtala, že keď chcem, nech idem, že ona to zaplatí a išiel som sem“
Závery analýzy priniesli niekoľko zaujímavých vhľadov do zmien, ktorými prechádza vzťahové fungovanie počas užívania drog tak, ako ich vnímali klienti/-tky s odstupom niekoľkých mesiacov po príchode do resocializácie. Najdôležitejšie sa týkali rodinného prostredia, opory a pomoci pri liečbe, prežívania blízkosti vo vzťahoch, a priorít v oblasti vzťahov.
Zapojenie klientov/-tiek v prvých mesiacoch resocializácie do nášho pilotného výskumu predstavuje zároveň silnú aj slabú stránku štúdie. Limitáciou je, že ich výpovede môžu byť skreslené selektívnym rozpamätávaním sa na minulé udalosti, t.j. vzťahy počas užívania drog. Silnou stránkou je, že takto sme získali výpovede aj od takých klientov/-tiek, ktorí z resocializácie odídu predčasne. Zistilo sa, že pacienti/ -tky, ktorí zostanú v liečbe dlhšie sa môžu líšiť v podstatných črtách od tých, ktorí liečbu ukončia predčasne3.

Prečo je dôležité rozprávať sa o vzťach počas užívania drog


Kvalitatívne rozhovory, ako výskumná metóda, neumožňujú zovšeobecnenie výsledkov na všetkých UD kvôli nízkemu počtu účastníkov/-čok. Na druhej strane kvalitatívny výskum pomáha prekonávať obmedzenia kvantitatívne orientovaného prístupu, tým že nachádza jedinečnosť, preveruje predsudky, mýty a nuanse interpersonálneho fungovania. Vytvára tak lepšie porozumenie v oblastiach, ktoré sú ťažko prístupné vedeckému skúmaniu. Porozumieť vzťahom znamená pre pomáhajúce profesie pristupovať bez predsudkov, lepšie pomáhať a zabraňovať udržiavaniu stereotypných predstáv o UD. Pre samotných klientov/-tky liečebných zariadení to uľahčuje vyrovnávať sa s vlastnou minulosťou a umožňuje rýchlejšie zakomponovať obdobia užívania drog do obrazu o sebe, či do osobnej histórie. A nakoniec, prínos pre širšiu verejnosť spočíva v zlepšení postavenia UD v spoločnosti, znížení marginalizácie a tým pádom prispieva k uľahčeniu prístupu k pomáhajúcim organizáciám.

Poznámky a literatúra:

6. Klimas, J. (2013). Vztahy, drogy a socialna prevencia v resocializacii. Socialna Prevencia, (1):25-26.
*Základ tohto článku tvoria príspevok prednesený na kvalitatívnej konferencii v Brne, 21. Januára 20104 a články v časopisoch Adiktologiea Sociálna prevencia6. Pri tejto príležitosti by som sa rád poďakoval Dr. Petrovi Halamovi za konzultacie a Dr. Matúšovi Bieščadovi za pomoc s analýzou rozhovorov.

Retention versus continuity of care?

Retention in treatment has been traditionally regarded as a key outcome measure of addiction treatment. Thinking about this indicator brings us to fundamental questions of what a success in treatment is and how it can be measured.
The longer drug users stay in treatment, the higher their chances of success. Their health improves; they commit less crime and have more stable daily routine. Early identification and treatment of drug problems is also associated with better outcomes. NIATx, for instance, is an easy to use model of process improvement designed specifically for behavioral health. It helps substance abuse and mental health treatment organizations improve user access to and retention in treatment, defined as “attendance at the second, third, or fourth outpatient treatment sessions”. Others regard 12-month retention in care as success.
Rowdy Yates said, at the INEF conference in Dublin, 2011 that drug users seeking treatment want to give up drugs and what they get from us? Methadone [a replacement opioid]. This statement reflects the inability of many treatment systems to offer a menu of options and tailor them to individual needs of drug users. Medicating drug problem is one of the solutions that work for a large population of treatment seekers. Other options should be offered too.
Dr Okruhlica, in Slovakia, agrees with the diagnosis of addiction by the International Classification of Disorders (ICD) or Diagnostic and Statistical Manual DSM. This definition lists several symptoms of addiction. If somebody has certain number of these symptoms, they receive the diagnosis. If the person doesn’t have symptoms for a year, they cannot be regarded as ill any longer. Harm reduction experts believe that while the medical diagnosis of addiction could be helpful in understanding the problem, even the most dependent users have control over their drug use and choice plays an important role in their life. Dr Zinbergwas a pioneer of this approach with his monograph The Basis for Controlled Intoxicant Use. Studies on uncontrolled drug use followed. These views are regarded as extreme by many. Their believability is further undermined by the fact that non-problem drug users live in anonymity. For example, very few scientific studies manage to engage with non-problematic heroin users.
On the other hand, the recovery-oriented movements, especially AA, maintain that once a person “gets” addiction, they will become ill forever. This opinion can be very helpful for people in treatment, but can actually harm people out of treatment. Ex-users seeking re-integration into job markets are viewed as irresponsible and incapable of holding jobs for long time – result of a society stigmatization.
Because retention in treatment, as a robust outcome indicator, is highly esteemed in the drug addiction field, most professionals working in the addiction are able to place them somewhere on the continuum delineated by the two extremes – illness for life vs. uncontrolled drug use. See figure 1 below.
Figure 1 Continuum of opinions
Alongside the controversy around medicalization of drug use runs another debate about language. For many, language doesn’t matter too much and is a matter of political correctness. Opposite to them, I would like to hope, stand the language-believers. For them, the words we use shape and influence the world we live in. If we call drug users “junkies” they will become “junkies” – whatever that word represents to those who use it. Similarly, the term retention could be too close to detention; people are not kept in treatment to help them regain life, but to help sustain the treatment centre. Just like in the prison, where the inmates have little control over their length of stay, the people detained or retained in treatment have little control over length of their treatment. Opponents of the word retention propose continuity of care as an alternative, more humane, term to describe this golden-standard treatment outcome indicator. For them, it incorporates also the individual willingness to receivecare. But, are patients aware of it? I ask.

Language shapes and influences the drug treatment systems that we study or work for. It is important to recognize that even though retention and continuity of care could be the same thing – looked at from different angles – we have to choose the words we use in treatment carefully and make sure people who use our services are aware of it.

Relationships of drug users change, but slowly

relationships change

Are social relationships sensitive to therapeutic change?

The ‘‘Phase Model of Change’’ –  a famous model in psychotherapy – says that change in overall functioning in life, including interpersonal problems, occurs during later phases of therapy. Well-being and symptoms take precedence. Social problems may last long, but this cross-sectional Slovakian study showed it’s worth asking drug users about their relationships. Intrusiveness and affectionate support seem to be the key players.

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