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| Recommendations from the Nation's Leading Addiction Researchers: Part 1 |
| Columns - Research to Practice | |
| Written by Michael J. Taleff, PhD, CSAC, MAC | |
| Friday, 13 April 2007 | |
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An important new book was recently published, Rethinking Substance Abuse: What the Science Shows, and What We Should Do About It (Miller & Carroll, 2006). It brought together some of the best addiction minds in the country to discuss the latest and greatest addiction research, and the implications for the addiction field. An interesting speculation was put forth. What would our field look like free of its never-ending politics. That set the stage for a later chapter that included a set of 10 principles intended to revamp substance abuse treatment. Those principles constitute the core of this column. An important new book was recently published, Rethinking Substance Abuse: What the Science Shows, and What We Should Do About It (Miller & Carroll, 2006). It brought together some of the best addiction minds in the country to discuss the latest and greatest addiction research, and the implications for the addiction field. An interesting speculation was put forth. What would our field look like free of its never-ending politics. That set the stage for a later chapter that included a set of 10 principles intended to revamp substance abuse treatment. Those principles constitute the core of this column.Because all 10 principles were difficult to squeeze into one research to practice column, this particular column covers only the first five principles (Part I), while the next column will cover the remaining five (Part II). The book also outlined a set of broad recommendations for the field, but as is the custom for this column, a more practical, day-to-day set of treatment recommendations are given for each principle. One overarching do-it-yourself research project that encompasses both Part I and Part II is presented. Rethinking substance abuse principles 1. Drug Use is a Chosen Behavior. Traditionally, addiction has been viewed as deterministic in that causal factors override conscious control and rational choice of addiction clients. However, research indicates drug use is choice, a bad one to be sure, but a choice among many. Moreover, that choice is affected by the learning and motivation principles that generally mold human behavior. The willful element of drug use has traditionally been minimized in the hope that compassion would replace the stigma long associated with addiction care. Yet, according to the research, intention plays predominant role in drug using behavior. The treatment implication here is to treat the client as an active participant, a responsible agent in therapeutic process; not a passive agent who is incapable of rational choice and believed to need confrontation. 2. Drug Problems Emerge Gradually and Occur along a Continuum of Severity. This particular finding is not exactly new, but reinforces something most, if not all, addiction professionals already know. Addiction takes time to grow and gets worse with increased abuse. An interesting thing about this principle lies in the fact that there is no clearly identifiable moment when someone becomes addicted. The continuum is overshadowed by shades of gray. The treatment implication here is that one needs to carefully gauge where a client is on this continuum to assure that the right treatment is being applied at the right place and time. 3. Once Well Established, Drug Problems Tend to Become Self-Perpetuating. Again, most addiction professionals do not see this as a revelation. Yet, research confirms years of anecdotal observations that despite the varied reasons people begin abusing drugs, once an addiction really starts, it creates a robust life of its own, and that there are many routes to this final stage. Some center on the pharmacological effect or the feeling elicited from the drug. In other words, it just feels so good to do. Others onset reasons include the avoidance such as stress, pain and similar reinforcements. Still, others involve modeling from family members of associates in a peer group. The treatment implications from this principle include thoroughly assessing what drives and maintains the abusive behavior. That evaluation will be differ among clients. In addition, the research also confirms the belief that established drug problems are resistant to treatment — one’s ability to control it, punishment or even religion. Treatment implications from these research finding indicate that deflating this robust system is going to be a challenge. So, expect relapse to occur, take a broad picture of the factors involved in the addiction process, and try not to get too demoralized. 4. Motivation is Central to Preven-tion and Intervention. Data indicates that factors of motivation play a central role in the understanding of abuse, as well as in its treatment and prevention. This is evident from the research conducted on people who quit on their own. Those reasons are remarkably similar to the reasons given by folks who quit via the formal treatment route. Many come to a choice point that was instigated by events caused by the addiction. The choice point is preceded by various stages of change that lead to increased concern to commitment, and finally, action. Interestingly, once a personal commitment is made, the data suggests that the person in question may not need much more assistance with the overall change process. The research associated with this principle indicates a couple of important implications. First, action speaks louder than words. That is, outcomes improve once clients start doing things that contribute to change, such as attending 12-Step meetings, following the recommendations of a treatment plan, or taking medications as prescribed. Next, the traditional saying, “it works if you work it”, is not limited only to Alcoholics Anonymous (AA) or similar groups. Treatment — any treatment — will work if one works it. Lastly, the notion that one has to hit bottom before one can change is a misnomer. There are any number of positive reinforcements and interventions that can be applied to any motivational level. Research notes such factors get results. 5. Drug Use Responds to Rein-forcement. Drug use and its effects are powerful reinforcements. However, that means that it is not only responsive to that which keeps it going, but also to that which will slow it down and or stop it. The problem is and generally has been finding the reinforcements that slow down or stop the drug use. The treatment suggestions here include: conducting a thorough, if not persistent, search to find even one thought, feeling, or action that produces a dent in the abuse. That, of course, will vary from client to client. But to find this reinforcement is easier said than done. Yet, once the abuse behavior stops, the focus shifts to finding long-term reinforcement that will reward a drug free lifestyle. One small research finding that complicates things is that the chronic abuse of drugs tends to shorten one’s time perspective. That is, the immediate rewards of drug use become the norm in terms of the reliable and almost immediate reward from the drug use. So, the typical rewards found in sobriety that have an inherent delay element to them, compared to the immediate effects of drugs, are often discounted by clients. Those clients who tend to discount the delayed rewards are at higher risk to continue drug use and abuse. This phenomenon is seen almost every day by counselors. One practical treatment suggestion is to include in your overall treatment plan, those medications that reduce rewards gained by the drugs. Those drugs include Naltrexone, Campral, and the emerging associated medications. Research you can do These combined principles suggest a rather simple research project for those of you who are so interested. The idea here is to compare your program in terms of outcome, prior to using some or all of the above variables, to after you institute their use. The control portion of the project can be your program or personal practice before you integrated these principles. To start, you first need to evaluate your program or practice on whether or not you utilizing these principles at this particular time. If not, or if you are only using a few principles, then establish a baseline for measurement. This baseline is going to be the thing you want to observe in terms of change. So, the baseline in this case will be the outcome of your program. Those variables could include abstinent time, reduction of drug use, number or arrests post treatment, emergency room visits and the like. You may already have that data. Now, begin to train your staff or yourself on these principles and then institute them within your program. Once you begin to institute the principles then re-assess your baseline from that point on for about six months. Again, use the same outcome variables (see above) for your second baseline. Then, measure the two baselines looking for any changes between them. This research is not going to be very strict in terms of classical research procedures, but it might give you some useful knowledge and ideas. As always, I remain interested in your findings. Reference: Miller, W.R & Carroll, K.M. (2006). Rethinking Substance Abuse: What the science shows and what we should do about it. New York: Guilford              |
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