Treatments for Addiction (Edexcel A-Level Psychology): Revision Notes

Treatments for Addiction

Introduction to treating drug addiction

When addressing addiction, treatment approaches must consider the various explanations for addictive behaviour. Different theoretical perspectives suggest different treatment methods. For instance, the learning perspective advocates for aversion therapy, while biological approaches may favour drug-replacement programmes.

The main treatment categories include:

• Drug-replacement programmes (e.g., methadone for heroin addiction)
• Behavioural programmes (e.g., aversion therapy)
• Cognitive programmes (e.g., hypnotherapy, cognitive behavioural therapy)

Treatment for heroin addiction

Methadone treatment programme

Drug-replacement programmes provide individuals dependent on illegal drugs with an alternative substance that is medically supervised. The primary objective is to help the person gradually decrease their drug consumption whilst avoiding the dangerous side effects associated with contaminated illegal drugs. For heroin users, these programmes often involve oral administration of the replacement drug rather than injection, which poses fewer health risks.

Methadone is a synthetic opiate, meaning it is a drug that mimics the effects of opiates such as heroin. It functions by replacing heroin at the synapse, enabling the drug user to maintain normal functioning. By providing methadone as an alternative, individuals can avoid the severe withdrawal symptoms that occur when heroin is absent from their system.

Medical professionals determine the appropriate dosage for each individual. Since excessive methadone can be harmful, doctors typically begin with a low dose when the person first starts the programme. Over subsequent weeks, the dose may be increased until it achieves a therapeutic effect. Individuals must have their drug use supervised at a pharmacy until professionals are confident they can be trusted to keep small quantities of methadone securely at home.

Methadone forms part of a maintenance programme, so former heroin users often continue taking methadone for extended periods. However, some individuals can reduce their methadone dose and eventually discontinue it entirely. Once a person has been stabilised on methadone, the process of detoxification can begin. The methadone dose is reduced slowly over time. Withdrawal symptoms still occur when coming off methadone, but reducing the dose gradually can minimise or almost entirely eliminate any negative symptoms that withdrawal may cause.

At the end of the detoxification process, the person no longer feels the need for methadone and, importantly, no longer considers themselves dependent on heroin for normal functioning.

Evaluation of methadone treatment programmes

Strengths:

The approach can require many months to achieve complete reduction and detoxification, as the decrease in substance use occurs very gradually. This necessitates long-term engagement with the programme. The gradual nature of the treatment makes it suitable only for those committed to a long-term programme rather than those wanting to stop drug use immediately.

The treatment programme addresses some social influences on drug use, including reducing the need to approach drug dealers. This decreases exposure to other drugs. When individuals are not spending time with others who share drug-taking attitudes, this can positively affect external influences. Drug-replacement programmes therefore address the nurture explanations of drug use, such as those proposed by social learning theory.

Medical professionals carefully control and oversee the treatment programme, making it much safer and more effective than simply stopping heroin use. Since unpleasant side effects can occur when withdrawing from substances, undertaking treatment in a controlled manner provides better support. Hedrich et al. (2012) found that starting a methadone programme for offenders in prison and continuing the support into the community had a positive effect on success rates, with more offenders remaining drug-free when released into the community.

Methadone, and other oral medication, avoids dangers of contracting blood-borne viruses, such as hepatitis or HIV, due to sharing needles with other drug users. It can also prevent other health complications through needle use when taking drugs, such as blood clots. This provides an additional short-term health benefit whilst reducing substance use.

Weaknesses:

Drug-replacement programmes do not address the reasons why the person started using heroin initially. This leaves people vulnerable to resuming drug use if the underlying reason for their initial use is not also addressed alongside the physical addiction. Hasan et al. (2014) found that combining drug-replacement programmes with psychosocial support increases the likelihood that a person will not return to drug use. This demonstrates that the psychological treatment enables the person to address the underlying motivation for their drug use.

The giving of methadone prescriptions for the user to keep in their home has resulted in media attention in recent years, often due to young children getting hold of the drug and drinking it themselves, or the user selling the drug to other drug users. Such decisions are, however, made by professionals after thorough investigation about the safety of others.

Detoxification programme

A detoxification programme aims to reduce heroin levels in the body in a controlled manner. Detoxification programmes provide supervised withdrawal from a drug of dependence so that the severity of withdrawal symptoms and serious medical complications are minimised. Supervision usually occurs in the period immediately after the person stops taking heroin, when the typical 'rebound' symptoms of drug withdrawal are at their most severe.

During a detoxification programme, the emphasis is on the physical effects of heroin addiction. The aim is to reduce heroin levels in the body so that the body can return to normal functioning, without the influence of heroin on the synapses. It represents a somewhat simple approach to treating heroin addiction in that the individual is observed and monitored whilst experiencing withdrawal from heroin.

Clinical support is likely to be provided to the individual within an in-patient facility, but this support is not a structured therapeutic approach during the acute withdrawal phase. Some detoxification programmes offer additional treatments such as cognitive behavioural therapy (CBT) to address the individual's beliefs and attitudes around their substance use. Holistic treatments, such as acupuncture, may also be offered, which aim to reduce some of the physical discomfort experienced during detoxification.

The unpleasant feelings of withdrawal can act as an aversive stimulus for heroin users, which can then act as a barrier to them engaging in detoxification in the absence of a substitute such as methadone.

Evaluation of detoxification programmes

Strengths:

Detoxification is a process that aims to achieve a safe and humane withdrawal from a drug of dependence. It does not address the reasons why the person started taking the drug initially, nor does it provide the individual with any strategies or support to address any future temptation to use heroin again. As a result, the potential for relapse remains high. Since it only addresses the physical addiction to the drug, it can be considered an overly simplistic way of addressing heroin use.

Detoxification is often conducted in conjunction with heroin replacement programmes, such as the use of methadone. To undertake detoxification (even in a controlled manner) in the absence of a replacement substance can be distressing and uncomfortable for the individual. This makes it less likely that an individual will want to engage in a detoxification-only programme.

Weaknesses:

The detoxification process can start as soon as an individual stops taking heroin. Whilst it is unpleasant, after a week without taking the drug the worst of the withdrawal symptoms have passed. This provides a quick way to reduce heroin levels in the body, whereas methadone programmes can take many weeks before an individual is no longer taking any substance.

As a result, an individual may have a period of time to wait before they can access a detoxification programme. During this waiting time, they remain vulnerable to continued heroin use, potential harm as a result of their use and the likelihood that they could change their mind about accessing the treatment.

Treatment for alcohol addiction

Aversion therapy

Another approach to changing substance behaviour is to directly address the behaviour itself. The behavioural approach advocates that new behaviour can be 'learned' in order to overcome addictions and replace addictive behaviours. Aversion therapy is one such behavioural treatment and is based on learning theory. One of the basic principles of learning theories is that all behaviour is learned and, on that basis, undesirable behaviours can be unlearned under the right circumstances.

It is based directly on the classical conditioning approach of learning theory. The goal of aversion therapy is to decrease or eliminate undesirable behaviours. It has been applied to a number of addictions, including smoking.

When someone drinks alcohol, the body metabolises the alcohol by turning it into a substance called acetaldehyde. This is a toxic compound that can cause the unpleasant symptoms associated with excess alcohol consumption such as vertigo, weakness, headache, anxiety and possibly even chest pain. Acetaldehyde is usually broken down quickly in the body and made into acetic acid, which is harmless.

Whilst disulfiram has been in use for many years, there have been recent advances in similar, but more developed, medications to use within aversion therapy. Medication that works in the same way of developing aversive symptoms but also rewards abstinence with positive feelings has had encouraging results. This medication, tryptophan, is known to increase levels of the neurotransmitter serotonin, which is associated with feelings of optimism, tranquillity and general well-being. Therefore, people who take this drug will not only abstain from alcohol but will feel more positive whilst doing so, which acts as a positive reinforcement for abstaining.

Evaluation of aversion therapy for alcohol

Strengths:

Aversion therapy differs from therapies that adopt principles of operant conditioning. Therapy using an operant conditioning approach would present the aversive stimulus, usually called punishment, after the behaviour rather than together with it. In presenting the aversive stimulus at the same time as the unwanted behaviour, it has a greater treatment effect based on the principles of classical conditioning. Ethical concerns have, however, been raised about deliberately making people experience unpleasant symptoms, even if they do give consent to the treatment.

Aversion therapy can be very effective in the short term as the unpleasant side effects are immediate, therefore creating an immediate behaviour change. However, relapse rates are high with this therapy. The individual is also still likely to have cravings as these are not addressed by taking the medication. It is usual for aversion therapy to be combined with other forms of treatment to address the motivation for the behaviour. Without other forms of treatment in addition to the aversion therapy, the person may simply replace the old undesirable behaviour with a new undesirable one.

Weaknesses:

The person is not required to have any insight into why they engage in the behaviour, which is often the case for more cognitive treatments such as CBT. However, it could be argued that if a person does not understand their motives for drinking, this could make them vulnerable to returning to the substance again in the future.

This treatment can only be used for people who want to abstain completely from alcohol. It is not an appropriate treatment for those who want to reduce their drinking to within safe limits. Behavioural change is needed instead for such individuals. Learning explanations would be interested in exploring what makes them drink excessively, such as peer influence, the environment they drink in, etc.

Cognitive behavioural therapy (CBT)

CBT is a talking therapy that uses a problem-solving approach to alcohol dependence. It aims to identify unhelpful and unrealistic thoughts and beliefs that may be contributing towards an individual's alcohol dependence. These can include reasons why a person chooses to drink, which may include as a way of relaxing or to cope with problems.

Once an individual has identified the thoughts and beliefs that keep them drinking, the individual is encouraged to change their thoughts to be more helpful. For example, an individual may believe that they are unable to relax without drinking. CBT may help the individual to instead believe that they have other ways they can relax, besides alcohol. They will then be encouraged to engage in the alternative behaviour to help them to relax, once they have an awareness of such alternative behaviours.

Evaluation of CBT for alcohol

Strengths:

McCarthy (2008) found that CBT was effective in reducing binge drinking but also demonstrated an increase in the ability for individuals to refuse alcoholic drinks when in high-risk situations. This indicated that the therapy was helpful in addressing the drinking behaviour itself, as well as the individual's coping abilities when in situations that would typically result in alcohol consumption. This two-fold approach increases the likelihood that an individual will be able to manage their future alcohol consumption by providing skills that can be applied when needed as well as encouraging behaviour change.

Many evaluations for the effectiveness of CBT for alcohol use are undertaken under the umbrella of 'substance use', which also includes drug use. It is therefore difficult to extrapolate the effectiveness of this therapy approach solely for alcohol use.

Weaknesses:

For some people, spending time with a therapist discussing their alcohol use may be sufficient to create a change in behaviour, as the individual may feel supported by the therapist and, therefore, empowered to make a change in their behaviour. It is therefore possible that simply discussing their alcohol use results in behaviour change, rather than specifically the components of the therapy itself. In this sense, it is difficult to determine if the positive therapeutic relationship creates behaviour change or the skills taught within the therapy.

Treatment for smoking addiction

Aversion therapy for smoking

Aversion therapy has been proven to be effective not only in alcohol use but also with other substances, including smoking. This treatment approach aims to pair smoking with unpleasant, aversive stimuli that remove the rewarding feeling experienced by smokers and replace it with an unpleasant one, with a view to the individual no longer wanting to smoke. The process of aversion therapy as a treatment for smoking follows the same process as with other stimulants, such as alcohol. The only difference between aversion therapy for smoking another substance is the aversive stimuli being used.

Aversion therapy is commonly applied to smoking through the method of rapid smoking. This involves inhaling on a cigarette every few seconds for several minutes whilst concentrating on the unpleasant feelings that arise from smoking so quickly. The participant continues the quick-puff procedure until they begin to feel nauseated. This serves to replace the association between the pleasurable or comforting feelings most people get from smoking with the more repulsive consequences of tobacco use.

Similarly, silver acetate products serve as a pharmacological aversive stimulus. They can be taken in the form of chewing gum, lozenges and a mouth spray. When taken with cigarettes, silver acetate produces an unpleasant metallic taste in the mouth and therefore has aversive qualities for smokers.

Evaluation of aversion therapy for smoking

The effectiveness of aversive stimuli with smokers has received limited empirical evaluation to date. As a result, it is not fully known how effective this treatment is in order to achieve long-term smoking cessation. Hajek and Stead (2000) found limited evidence that rapid smoking (inhaling deeply and frequently) might reduce smoking. Existing trials show little evidence for a specific effect of silver acetate in promoting smoking cessation. The lack of effect of silver acetate may reflect poor compliance with a treatment whose rationale is to create an unpleasant stimulus, rather than the treatment method itself being ineffective.

Hypnotherapy

There are many psychological treatment programmes available that can be used to address addiction behaviour. CBT is one way in which individuals can be guided to use self-talk strategies at times of cravings to support themselves when wanting to drink alcohol or smoke a cigarette. Another approach that has been gaining credibility as a treatment, particularly for nicotine addictions, is that of hypnotherapy.

Hypnotherapy occurs when a trained therapist induces a client into a very relaxed state. This can make them more open to suggestions put to them by the therapist, thus making them more suggestible.

The client is not put to sleep, but their focus reduces to the extent that they are no longer aware of anything other than the words of the hypnotherapist. Their level of consciousness has been altered when placed under hypnosis before the treatment commences.

In this relaxed state, ideas can be implanted into the client's unconscious that will influence the person's behaviour once they are in a more conscious state. When addressing addiction behaviours, the therapist will suggest ideas such as the person no longer wants to smoke or to imagine unpleasant outcomes if they were to smoke again. These suggestions then form part of the client's own thoughts and are remembered when in a conscious state. When the person thinks about smoking they will then think about these thoughts, which will put them off smoking.

Evaluation of hypnotherapy

Strengths:

Hypnotherapy has been found to be three times more effective as a treatment in addressing nicotine addiction than nicotine replacement therapy (Hasan et al., 2014). This supports the psychological influence of nicotine addiction, whereas nicotine replacement therapy focuses on the biological sources of nicotine addiction. As such, it addresses and seeks to change the psychological components related to continued smoking behaviour. Other treatment methods tend to just focus on the physical dependency that maintains smoking behaviour.

Hypnotherapy can be more helpful than other techniques, such as drug treatments, as it supports the self-belief of the person, that they are able to make positive changes for themselves, without feeling that they need medication to help them with it. Positive treatment outcomes can often be seen after just one or two treatment sessions. This makes it a very cost-effective treatment. For treatments such as methadone reduction, treatment takes a prolonged period of time before positive outcomes can be seen.

Weaknesses:

Some people may be put off from trying hypnotherapy as they may think that they are not going to be in control of their behaviour or that they may be vulnerable during hypnosis. As a result, they may be more likely to try other treatment options.

Treatment success relies on the client being able to relax sufficiently to be hypnotised. If they cannot do this, the auto-suggestions will have no benefit on the individual. Therefore, it may not be a treatment that will be suited to everyone, although the individual will not know if it will be effective or not until they have tried it.

Motivation as a precursor for treatment

For treatment to be effective, a person using the drugs has to want to change their behaviour. A common psychological model that identifies an individual's motivation, designed specifically with drug addiction in mind, is that of the 'Stages of Change' Model (Prochaska and DiClemente, 1983). It is an influential model within psychology as a discipline, no more so than in relation to identifying treatment options for drug users.

If a person were to return to drug use at any point (that is, have a relapse or a lapse), they will need to make a decision about what they want to do next, and re-enter the stages of change.

The model is considered to be a cycle that a person goes through in order to manage their addiction. The model is therefore often referred to as the 'cycle of change'. An individual's positive, ongoing motivation to address their drug use will move through each of these stages, in the direction shown by the arrows. Motivation may also, however, go the other way, and would suggest the person is less motivated or feels less ready to make positive changes to their drug use.