BASIC PRINCIPLES

The two major forms of treatment for substance misuse, i.e. psychosocial treatments and pharmacologic treat- ments, have a number of differences in terms of mode of action, time to effect, target symptoms, durability and applicability across drugs of misuse. While each has specific indications and strengths, no counselling inter- vention or pharmacotherapy is universally effective, and both forms of treatment have some limitations, particu- larly when used alone. Outcomes can be broadened, enhanced and extended by combining the most effective forms of counselling and pharmacotherapy. Having said this, despite consistent findings which point to the effectiveness of counselling in this area, no particular technique has consistently emerged as superior to any other technique. One interpretation of these findings is that different types of patient may respond differently to different treatments, and by aggregating outcome data across different types of patient characteristics, differential treatment outcomes may be obscured. Whilst major programmes of research such as Project Match (Project Match, 1993) have failed to describe particular patient characteristics indicating likely responsiveness to particular treatment modalities, there remains widespread support for the effectiveness of a needs-led approach. People often seek help when they are locked into a chaotic life cycle, and effective treatment can only be achieved by addressing the whole range of needs.

In general, pharmacotherapies have a much narrower application than do psychological therapies for substance abuse. Most counselling techniques are appli- cable across a range of treatment settings (e.g., inpatient, outpatient, residential), modalities (group, individual, family), substances and populations. For example, Twelve Step, behavioural, or

motivational approaches can be used, with only minor modifications, regardless of whether the client is an opiate, alcohol, cocaine, marijuana or barbiturate user. On the other hand methadone produces cross-tolerance for opioids but has little effect on concurrent cocaine abuse, while disulfi- ram produces nausea after alcohol ingestion but not after ingestion of illicit substances. A notable exception is naltrexone, which is used to treat both opioid, and more recently alcohol dependence.

There is substantial evidence in support of the enhanced effectiveness of combined approaches. For example, McLellan et al (1993) demonstrated superior outcomes for patients randomised to methadone maintenance plus regular individual counselling, medical/psychiatric therapy, employment and family therapy as opposed to methadone maintenance alone or methadone maintenance plus counselling. The latter group had intermediate outcomes. Naltrexone therapy to prevent relapse to opiate misuse, has failed to live up to its early promise, with high early relapse rates. However, the addition of behavioural and psychothera- peutic interventions to naltrexone therapy has been demonstrated to improve outcome (Anton, 1981).

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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.