Written by: Dominic Denison-Pender, Business Development Director at The New Life Centre.
Medically Reviews by: Dr Amal Beaini MBChB FRCPsych (Medical Director and Consultant Psychiatrist at The New Life Centre)
1. Substance Abuse: A definition
“Substance abuse” is a long established term to cover the use of a drug in amounts or by methods which are harmful to the individual or to others. Some prefer the less derogative term “substance-related disorder”. Differing definitions of drug abuse are used in public health, medical and criminal justice contexts. Drugs most often associated with these terms include: alcohol, amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, hallucinogens, methaqualone, and opioids. The exact cause of substance abuse is not clear, but there are two predominant theories: either a genetic predisposition or a habit learned from others, which, if develops, manifests itself as a chronic debilitating disease.
2. Substance abuse or substance addiction?
In short, substance abuse can lead to addiction given that all the substances generally included under the term “substance abuse” have patientive properties.
Some analysts recognise 4 stages that lead to addiction:
- Stage 1: Experimentation, defined as the voluntary use of alcohol or drugs without experiencing any negative social or legal consequences. Consumption usually has the aim of achieving a pleasurable “high”, often in a social context. Some can resist going beyond this stage, but others fail to do so
- Stage 2: Regular Use, when the occasional drink or drug turns into a common occurrence. This can have consequences such as damage to health, driving under the influence etc. Some can keep it under control. Others think they can but in truth cannot. Drinking or drug taking on your own is especially dangerous.
- Stage 3: High Risk Use, when substance abuse starts to become dominant, taking priority over other aspects of life
- Stage 4: Addiction, or complete dependency on the substance. This is typically accompanied by very unpleasant withdrawal symptoms when an patient loses access to the substance or tries to give up.
In recent years there has been a tendency away from treating addiction as a human failing towards treating it as a medical condition. This has been prompted in part by the prescription opioid crisis in the USA (and on a lesser scale in the UK) where the over prescribing of opioid painkillers has led to widespread addiction (and indeed overdose deaths) through no initial fault of the patient. This more compassionate approach fits awkwardly with the fact that much drug abuse is inherently illegal, making it very difficult to strike an acceptable balance between remedial treatment and punishment.
3. Therapies available for substance abuse: an overview
There is no cure for addiction. Escape from addiction is rather a process. In considering how addiction is managed, a distinction needs to be made between therapies and treatments. The two might conveniently be grouped together under the umbrella of addiction rehabilitation. Before looking in more detail at the therapies available for substance, it is worth putting such therapies in context by first identifying the main addiction treatments being offered in the UK. Broadly speaking treatments attempt to achieve specific goals:
- Medication assisted detoxification aims to achieve abstinence, after which the challenge is to sustain abstinence
- Opioid Substitute Treatment (OST) aims to take patient off dependence on illegal or prescription opiates by replacing them with less harmful opioid substitutes such as methadone and buprenorphine. The eventual aim is to wean the patient off the substitutes as well, but the process can drag on for months or even years, with the risk of relapse to the illegal substance always present
- Naltrexone based relapse prevention treatment can only be initiated once the patient is fully “clean”, so normally needs to follow a medication assisted detox. The naltrexone blocks the impact of the patientive substance if it is taken in relapse.
By contrast the various therapies employed as part of addiction rehabilitation are in general supportive aids to patients seeking escape from their patientive dependencies. They are not specific to any particular type of addiction.
The 12 Step Model
This is without question the most widely used addiction therapy in the world. Although it started as a response to alcoholism, it is now used for almost all types of addiction in most types of treatment settings.
The 12 Step model was the basis of the foundation of Alcoholics Anonymous (AA) in Ohio in 1935. The original list of the 12 Steps was as follows:
The following are the original twelve steps as published by Alcoholics Anonymous:
- We admitted we were powerless over alcohol—that our lives had become unmanageable.
- Came to believe that a power greater than ourselves could restore us to sanity.
- Made a decision to turn our will and our lives over to the care of God as we understood Him.
- Made a searching and fearless moral inventory of ourselves.
- Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
- Were entirely ready to have God remove all these defects of character.
- Humbly asked Him to remove our shortcomings.
- Made a list of all persons we had harmed, and became willing to make amends to them all.
- Made direct amends to such people wherever possible, except when to do so would injure them or others.
- Continued to take personal inventory, and when we were wrong, promptly admitted it.
- Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
- Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.
While the 12 steps in use today are based on the same ideas written by the founders of AA in the 1930s, the understanding of the term “God” has since broadened to refer to any “higher power” that a person believes in. The 12 Steps are supported by AA’s “12 Traditions” which are the spiritual principles behind the 12 steps. This embrace anonymity, singularity of purpose, non-affiliation to other bodies etc. The original approach was based on mutually supportive groups, of which Alcoholics Anonymous (AA), Drug Patients Anonymous (DAA) or Narcotics Anonymous (UKNA) are amongst those active in the UK. The 12 Step model is retained as the basic therapy in several of the UK’s best known addiction treatment clinics whose detox treatments are mostly abstinence based. It is also used by treatment facilities using OST for opioid addiction. The approach is spiritual and philosophical rather than scientifically psychiatric or medical. There is no doubt that the 12 Step model has helped countless people struggling with addiction. However even its most ardent advocates will accept that it is an aid rather than a solution to relapse prevention. The very poor treatment outcomes, especially for opioids, do signal that something more (or different) is needed.
Cognitive behaviour therapy (CBT)
Cognitive behavioural therapy (CBT) is a type of talking therapy. It is a common treatment for a range of mental health problems. It is not specific to addiction rehabilitation but it is used by some addiction treatment clinics.
CBT teaches you coping skills for dealing with different problems. It focuses on your thoughts, beliefs and attitudes affect feelings and actions.
Unlike some other talking therapies, CBT focuses on the current challenges rather than on past experiences. It aims to improve your state of mind by teaching you to spot the links between your thoughts, actions and feelings.
Doing CBT, involves working with atherapist to find new ways of dealing with problems, and set goals for what you want to change. When CBT is successful it can help you to feel more in control of your life.
Dialectical behavioral therapy (DBT)
Dialectical behaviour therapy (DBT) is an established treatment for individuals with multiple and severe psychosocial disorders, including those who are chronically suicidal. Those same type of patients are often also coping with addiction, so the technique is sometimes used in addiction rehabilitation settings.
Other “soft” therapies:
A wide range of other soft therapies are used by addiction treatment facilities (including those that do and those that do not use the 12-Step model).
- Art and music therapy
- Equine assisted therapy
- Drumming therapy
- Fitness, massage, acupuncture, and aromatherapy
- Family therapy
- Eye movement desensitization and reprocessing (EMDR)
- Creative workshops
- Yoga and mindfulness meditation
- Horticultural therapy.
- Contingency management.
Again, these are aids rather than solutions to relapse prevention.
4. What are the most effective therapies for substance abuse?
There is no data available on which to evaluate the relative effectiveness of the different therapies that form part of addiction rehabilitation programmes. The 12-Step programme is now so widely used in both alcohol and drug rehabilitation that it has become more or less accepted (perhaps rather uncritically) as standard practice. The mutual support groups such as AA, DAA and NA that are based on 12-Step do not as a matter of policy keep member records. 12-Step has certainly helped countless patients to the extent that they have been better off with it than without it. There is no evidence on which to judge whether, for example, 12-Step is better suited to alcohol addiction than to opioid addiction. It is interesting to note the mutual support group sessions are run to a large extent by volunteer ex patients, which is a testament to their faith in the approach.
However the stark fact remains that the most common approach to opioid addiction treatment is OST plus 12-Step, and the overall outcomes for opioid addiction treatment are very poor indeed. Therapies may be helpful but much more is needed.
5. Therapies available at The New Life Centre
The BONDS Protocol as practiced at The New Life Centre is more medical and psychiatric than therapeutic. The Protocol is based on rigorous dual diagnosis, medication assisted accelerated detox and medicated relapse prevention. One-on-counselling based on the dual diagnosis plays an important role. Individualised post discharge programmes may include sessions with therapists outside The New Life Centre. Broughton Hall itself has well established wellness programmes that can be used by New Life Centre patients after discharge.