Chapter seven

Drug abusers

Stirling Moorey

Over the last 10 years the role of cognitive factors in addiction has been viewed with increasing interest. The old-style disease model, which saw addicts as suffering from an illness which limited their control of their own actions, is being replaced by a self-control model, which emphasises individuals’ contribution through their thoughts and actions to their dependence on drugs. One of the features of this theoretical approach is its concern with the factors which various addictions have in common, i.e. the deficits in self-control which can be seen in such widely divergent areas as alcoholism, smoking, and heroin addiction (Levison et al. 1983). This chapter will mainly focus on illicit drugs rather than on the physically more damaging but socially condoned drugs such as alcohol and nicotine. Before pursuing the cognitive model of drug abuse further we will look at the conventional forms of treatment.

Treatment of drug abuse

Most workers in the field of addictions would see the problem as multifactorial in its aetiology. Psychological, social, and physiological factors all play a part in producing physical or psychic dependence on a drug. The approach to treatment is similarly eclectic, as far as resources allow, making use of the divergent skills of various disciplines. The modern drug dependence team consists of psychiatrist, nurses, social workers, and psychologists and has more and more a communityoriented approach with good links with local voluntary and self-help organisations.

The treatment of drug dependence falls into two phases: drug withdrawal and general treatment measures.

Drug withdrawal

The aim of all treatment of addicts is to free them from dependence on the drug. Some doctors advocate a period of maintenance on the drug before detoxification. In practice this usually applies only to opiates. The argument for this is that many addicts, particularly polydrug abusers, have an unstable, chaotic life-style, and if they are to overcome their addiction they need to be in as stable a condition as possible. Though plausible, there is little evidence to support this stance. Most doctors would suggest an immediate period of detoxification as an out-patient or in-patient. Before commencing withdrawal an assessment would be carried out over a number of sessions. A psychiatric and drug history is taken, together with details of the extent of present drug use. Physical examination may reveal withdrawal signs or signs of side-effects of drug abuse. If the person is dependent on opiates, three positive urine tests over a period of ten to fourteen days are usually needed to confirm dependence (Gardner and Connell 1970). Methods of detoxification vary depending on the drug used. The basic principle is to replace the drug with another which either has the same effects (e.g. methadone in heroin withdrawal) but can be reduced in a controlled way, or to give a drug which dampens some of the symptoms of withdrawal (e.g. benzodiazepines in alcohol dependence). For more details see Ghodse (1983).

General treatment measures

Getting the addict off the drug is relatively easy. It is prolonging this state of affairs which is difficult. The second phase of treatment will use a variety of measures with the aims of preventing relapse and resocialising the person into a drug-free life-style. The methods used depend on theoretical orientation, the particular problem of the addict, and the resources available. Some units offer a short-term detoxification followed by out-patient treatment with support groups. Others attempt a more radical change and advocate a long admission, often along therapeutic community lines, with the goal of helping the patient to learn more appropriate and mature ways of relating. Social work input to help with accommodation, training for and obtaining jobs, or helping with family problems is frequently used. Psychotherapy is rarely available, though in-patient or out-patient groups run along psychotherapeutic lines are more common. Many of these interventions are influenced by the old disease model, although this influence will not always be acknowledged. Residential treatment centres encourage avoidance of people and