Alexander DeLuca, M.D.
Learning the Language of Abstinence in Addiction Treatment:
|by Colin Brewer, MB, MRCPsych1, 3 and Emmannuel Streel; Substance Abuse, Vol. 24, No. 3, September 2003. Originally posted 9/25/04: [www.doctordeluca.com/Library/AddictionMeds/LearningLangOfAbs03.htm].|
Relapse-prevention (RP) is an educational process. Learning to abstain from alcohol or opiates after years of dependence involves selectively suppressing old, maladaptive habits of thought and behavior and establishing new, adaptive ones. This process resembles foreign language (FL) learning. Effective FL teaching techniques are relevant to RP. “Immersion,” the most effective FL teaching method, discourages students from using their ﬁrst language ab initio, requiring them to use the FL instead, however inexpertly. It resembles exposure and response-prevention for phobic or compulsive disorders. Supervised disulﬁram aids RP by discouraging alcoholics from responding to real-life drinking cues in the “language” of excessive drinking, requiring them, ab initio, to practice new, alcohol-free responses. Supervised or depot naltrexone acts similarly in opiate dependence. We discuss the concept of antagonist-assisted abstinence.
People who drink alcohol in a harmful or excessive way do so for a variety of reasons but many of those who request help or treatment have one thing in common: they ﬁnd it hard to give up the habit of drinking too much. For most of them, it is not simply a matter of learning to resist the temptation to drink—important though that is—but also of learning what to do in various common social, psychological, and emotional situations instead of drinking. Indeed, teaching patients how to cope in these situations is the main activity of most relapse-prevention programs.
While drinking remains a central feature of someone’s life, the question of alternatives to it rarely arises. Yet even when the need to learn an alternative is accepted, not all turn out to be good pupils, though many do. There is good evidence that for a signiﬁcant minority of alcohol abusers, once they accept that they have a problem, stopping or reducing drinking is often achieved with little effort and with little or no professional help (1). This phenomenon is similar to the considerable improvement reported by many patients in controlled studies of psychotherapy, following a single interview aimed at assessment rather than treatment (2). Such “easy” patients do well whatever treatment, and however much or little of it, they receive.
Conversely, we need not concern ourselves here with those patients whose extreme ambivalence about change is reﬂected in their refusal to cooperate with any suggested treatment. They do not merit therapeutic attention unless and until they become much less ambivalent, although we may be able to teach their families or employers effective ways of bringing them into treatment (3). Most therapeutic effort should be directed at those who, though willing in principle to learn new habits of thinking and behaving, ﬁnd—sometimes to their genuine surprise and annoyance— that the old habits continue to assert themselves.
This group demonstrate their willingness to learn by regular attendance at clinics or AA groups. If advised to have counseling, psychotherapy or assertiveness training, or to take medication such as acamprosate, they do so but keep on relapsing, often to the despair of themselves and their helpers. Sereny et al. (4) described 73 such patients with three or more relapses despite adhering to a comprehensive treatment program.
When this happens, there is a tendency to blame the patient and “poor motivation,” but if the patients are doing all that is asked, is there not perhaps a case for blaming (or at least examining) the methods used to teach them new habits? In any case, we should surely concentrate on the most efﬁcient and cost-effective methods of relapse-prevention, especially at the start of treatment when relapse may undermine the patient’s fragile belief in his ability to change.
One of us has previously suggested (5) that learning how to abstain is similar, in several important cognitive and behavioral respects, to the learning of a foreign language. In this paper, we develop the idea, review what is known about the most effective methods of foreign language teaching, and discuss their relevance to the learning of abstinence or moderation.
PRINCIPLES OF FOREIGN LANGUAGE TEACHING
Any English speaker who has tried to learn a foreign language knows how many obstacles there are to achieving ﬂuency. Initially, one continues to think in English and each individual word has to be mentally translated. Many people give up at this stage, or satisfy themselves with a few basic words or phrases. It is so much easier not to bother and to hope (not always in vain) that if you speak English loudly and slowly, foreigners will understand. When you have thought, spoken, cursed, joked, written, and dreamed exclusively in English all your life, it can be hard for those without special linguistic aptitudes to change.
Because learning foreign languages is an important area of education, and because politically or economically inspired migrations may require large numbers of people to be taught a second language quickly, much attention has been devoted to the various ways of teaching them. Consequently, much is known about which methods are efﬁcient and cost-effective and, equally important, which methods are not. Essentially, there are two approaches. Teaching in schools often uses a “dripfeed” approach in which students with varying degrees of motivation are taught in a fairly passive way for short periods once or twice a week. What they do between classes with the skills and information they acquire is left very much to them. Inevitably, many will hardly give it a thought from one lesson to the next. Other pupils may be genuinely keen to learn but if they do not see results quickly, disillusionment, boredom, or demoralization may set in. This method, described by Hawkins (6) as “gardening in a gale of English,” may be complemented occasionally by more intensive exposure, as on school visits to foreign countries, but such events, though generally seen as useful and logical, are exceptions to the usual pattern of “dripfeed” teaching.
The other approach regards intensive exposure or “immersion” as the norm and sees nonintensive, “dripfeed” exposure as an inefﬁcient use of teaching resources. Hawkins (6) states that “No-one seriously doubts how foreign languages should be learnt.” He notes that using intensive, all-day immersion, it is possible to get a class of adults up to GCE “O” level (the school-leaving exam for 16-year-olds) Italian Grade 1 in some 80 h spread over 2 weeks. This compares with 5 years for the normal school Italian syllabus. Signiﬁcantly, immersion methods are seen as making the educational process easier for both students and teachers. Hawkins argues that “If the optimum environment for our students is immersion, then we should be looking at ways of of making this possible, not as a fringe or marginal activity but as a central feature of at least some part of the learning program.”
There is nothing new about the immersion method. Hawkins points out that in Elizabethan England, Latin was taught by requiring it to be used for everyday communication and that the use of other tongues was strongly (and sometimes quite brutally) discouraged. Living in a foreign country for several months continuously (and not spending too much time with one’s compatriots) has always been regarded as an effective way to learn a new language and to absorb the cultural and historical attitudes associated with it. Language teachers call this “submersion.” It works presumably because it makes it even more difﬁcult for people to resort to their own language when faced with difﬁculties in communicating a particular idea while increasing their motivation to use the new language. Hawkins notes the paradox that “outside the classroom, half the world’s children effortlessly master two or more languages.” They do this by a combination of practice and necessity.
“Immersion” is not just a question of longer and more intensive language lessons. It means making the use and practice of the new language a routine and necessary part of daily life. In schools, this may involve teaching non-language subjects such as physics and geography in a foreign language. The important principle is that the new language is not treated as something separate from normal life.
Perhaps surprisingly for such an important activity, foreign language teaching (like most other areas of primary and secondary education) has not been subjected to the kind of classic, randomized controlled trials which are routine in medicine. However, there have been some comparative studies involving reasonably well-matched groups of primary and secondary school students. These show that “immersion” methods are more effective, achieve given levels of ﬂuency more rapidly and do not have adverse effects on ﬁrst language acquisition (7). “Submersion,” not surprisingly, seems to give even better results than immersion (8, 9).
Immersion methods are also routine in Israel where many immigrant families and individuals have had to learn Hebrew quickly. Teaching is in Hebrew from the start and learning basic phrases by heart is stressed. Grammar comes later in the course which typically involves 5 h a day for 24 days spread over 4 weeks. Some slow learners get individual rather than class tuition but the methods used are the same. This is consistent with comparative research (10) that stresses the importance of rote learning, practice outside the classroom, and concentrating on basic concepts. Immersion or submersion are also favored in most private language schools and high fees are charged for intensive courses which enable students to achieve useful levels of ﬂuency in as little as 1 week. For most purposes, it is more important and useful to have the conﬁdence to converse in a foreign language, even if imperfectly, than to have a good theoretical knowledge of vocabulary and grammar but lack the conﬁdence to use it.
ANALOGIES WITH THE TREATMENT OF ALCOHOLISM AND OPIATE DEPENDENCE
The equivalent of immersion or submersion in treatment for these conditions would require prolonged and repeated exposure to real-life alcohol or heroin cues and situations while strongly discouraging the actual consumption of alcohol or opiates. It would encourage the notions (or cognitions) that not using these substances— like not habitually speaking English—is compatible with a reasonably satisfying existence, that there are other ways of dealing with anxieties and sorrows than by drowning them, that temptation is not irresistible and that many individuals and cultures survive quite successfully without alcohol or heroin (or English).
Some alcoholism treatment programs do emphasize cue-exposure to alcohol, even providing pseudobars in which to practice abstinence in the presence of pseudotemptation. (For obvious reasons, this approach is rarely used for opiate addicts.) They also encourage the practice of alternative behaviors which do not involve using alcohol or opiates. These range from drinking alcohol-free beverages (and becoming assertive enough to demand them), through anxiety management to joining evening classes to get a new set of friends. Unfortunately, these programs are much closer to the “dripfeed” model of education than to “immersion” techniques. The counseling and group or individual therapy (the teaching) and the supervised exposure to real-life or, more commonly, simulated cues and temptations (the practice) will rarely last more than an hour or two at a time. Yet Hodgson (11) emphasizes “... the importance of practicing coping skills when facing temptation and not just in the peace and quiet of the therapist’s ofﬁce.” As with language, having the conﬁdence to use coping skills, even imperfectly, is more important than knowing what to do in theory but not being able to use that knowledge when it is most needed.
Unlike Englishmen living or working abroad, or students in a week-long immersion course, who cannot easily escape from the need to practice what they have learned, patients in most treatment programs leave the inevitably artiﬁcial atmosphere of the clinic to enter a world where it is easy to escape from the discipline of treatment. Many soon revert to old habits, often unthinkingly, and the temptation to do so is rarely absent. If drinking or heroin use do occur, the “abstinence violation effect” often combines with the effects of intoxication to increase the risk that the relapse will be a serious one. Even minor relapses may undermine the patient’s self-esteem and belief in his ability to change.
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WHY DISULFIRAM IMPROVES TREATMENT EFFECTIVENESS IN ALCOHOLISM
Disulﬁram deters drinking by the fear of an unpleasant reaction with alcohol. Controlled studies have repeatedly and consistently shown that disulﬁram, when given under supervision, can signiﬁcantly reduce the risk of relapse (12–17). By preventing alcohol use even outside the therapeutic situation and many days or weeks after the last therapeutic contact, supervised disulﬁram increases the likelihood that the new, alcohol-free patterns of behavior will be remembered, used when appropriate and, by repeated practice, properly or at least adequately performed.
This is entirely consistent with the theory and practice of relapse prevention, which emphasizes relearning, self-efﬁcacy, self-control and an altered self-image and sees alcoholism as inappropriate, learned behavior in general and as inappropriate coping behavior in particular. Control is regained by successfully and repeatedly confronting, without alcohol, the situations and attitudes which formerly resulted in excessive drinking (18, 19). Heather et al. (20) stress the importance of substance-related cues in relapse and note that patients rated them as the most important precipitant. Powell et al. (21) emphasize negative emotional states and social pressure. Tobena et al. (22) conclude that “To obtain maximum protection against relapse, extinction should “recreate” all the original learning contexts (i.e., all possible drug cues).” Compare this with Hawkins’ statements (6) about learning a foreign language. “The real language laboratory is the foreign country. ... One obvious explanation for failure to achieve ﬂuency is lack of exposure. ... Progress can only be achieved through extending the length of contact time between learner and language.” (Our italics.)
Both these statements have their parallels in effectiveness studies of exposure and response-prevention for phobias and compulsive disorders. For example, a single 2-h session of exposure for phobias or compulsions has been found to be more effective than four 1/2-h sessions (23). Similarly, exposure to real snakes gives better results in snake phobia than exposure to simulated or imagined serpents (24). Although several authors have noted the similarities between many relapse prevention programs and exposure treatment for phobias (22, 25) they largely fail to mention response prevention as an important component of successful exposure treatment.
For example, in treating spider phobia, one exposes the patient to images of spiders and then to progressively bigger, hairier, and more frightening dead and living spiders. At the same time, the therapeutic relationship is used to encourage the patient to remain in the therapeutic arena while using previously rehearsed coping responses. For compulsive behavior such as hand-washing, the therapist encourages the patient to get his (or her) hands dirty and then strongly discourages the normal washing response while the patient performs previously rehearsed alternative techniques for dealing with any ensuing anxiety. This loss of maladaptive responses involves the process of extinction described nearly a century ago by Pavlov. Dogs conditioned to salivate at the sound of a bell, which had originally been paired with the appearance of meat, eventually failed to salivate when repeatedly exposed to the bell without the simultaneous appearance of meat (26). Although Marks and Dar (27) recognize that factors other than exposure may be involved in the successful treatment of phobias, they conclude that “Exposure, cognitive therapy, and other approaches may all be teaching patients to uncouple thoughts/feelings from immediate action.”
Supervised disulﬁram facilitates confrontation with the situations and attitudes which resulted in drinking and increases “the length of contact time between learner and language.” Equally important, it prevents the habitual alcohol-drinking response in these situations. It thus converts any treatment program from the usual inefﬁcient, intermittent, drip-feed method of teaching and learning to one which resembles immersion or submersion with all their advantages (83). Carroll et al. (28) showed in a randomized controlled trial that supervised disulﬁram signiﬁcantly increased both abstinence from alcohol and cocaine and treatment retention compared with similar psychosocial interventions without disulﬁram. Furthermore, Azrin (12) showed that improved results in terms of abstinence and employment were obtained with less counseling compared with patients not having supervised disulﬁram. Similar ﬁndings were obtained by Azrin et al. (13) who noted that adequate family supervision of disulﬁram gave results at 6 months which were so good that they could not be improved by more intensive counseling.
The more automatic the new responses, the more effective they are likely to be, for as the 18th century essayist Hazlitt observed; “We never do anything well until we cease to think about the manner of doing it.” In other words, practice makes perfect. Interestingly, the French equivalent of this adage—“c’est en forgeant qu’on devient forgeron”—translates literally as “by doing the work of a blacksmith, you become a blacksmith.”
WHY NALTREXONE IMPROVES TREATMENT EFFECTIVENESS IN OPIATE ADDICTION
Naltrexone, an oral or implantable long-acting opiate antagonist, deters the use of heroin and other opiates by blocking their effects. Although there are fewer studies of supervised naltrexone than of supervised disulﬁram, the same principles are involved. Chan (29) did a clinical trial involving Singaporean heroin-abusing recurrent offenders released on parole. He showed that adding naltrexone, given under strict supervision thrice weekly, increased 12-month abstinence and probation compliance rates from around 25% to around 75% compared with an identical parole-linked treatment program without naltrexone, even though the program included regular urine testing, counseling, job-ﬁnding, and electronic tagging.
That in itself is an important and encouraging ﬁnding. However, the outcome at 2 years was perhaps even more encouraging. Naltrexone and tagging were discontinued after 12 months. The gradual attrition continued but the compliance rate at 2 years (including abstinence, as judged by regular urine testing) was still an impressive 33%. This suggests that even in this conventionally unpromising patient group, reexposure to their customary heroin-rich environment while their ability to use heroin was effectively blocked greatly enhanced and consolidated their ability to resist the temptation to use heroin even when the assistance of naltrexone was removed. Such prolonged and uninterrupted abstinence may be even more important for heroin users than for alcoholics since residual withdrawal symptoms may be much more persistent in opiate dependence than in alcoholism (30). Chan (31) has subsequently reported on a cohort of patients who continued probation-linked naltrexone for a further year. Seventy percent were still abstinent after 24 months, as shown by regular urine testing (31). A randomized controlled trial of twice-weekly probation-linked naltrexone in Philadelphia shows that the beneﬁts are not restricted to Singaporean society (32). The importance of supervised administration was also emphasized by Currie et al. (unpublished data). They showed that validated abstinence rates in local urban patients of around 60% 12 months after rapid naltrexone induction under sedation or anaesthesia fell to 25% in country patients who did not have access to the same follow-up program which emphasized the direct supervision of naltrexone.
OBJECTIONS TO THE ANALOGY
Heather (33) while accepting the speciﬁc effectiveness of supervised disulﬁram, questions the mechanism which we have proposed. He notes that extinction theoretically occurs only “when the consummatory response (i.e., drinking) is available. In other words, the individual must be exposed to temptation for extinction to occur. ... Secondly, it is possible that, for self-efﬁcacy to be increased in the manner suggested ... the patient must be able to attribute the success of coping efforts in the high-risk situation to him/herself [rather than] to an external agency (ie the disulﬁram).” A similar point is made by Annis (34).
We reply, ﬁrstly, that drinking alcohol and using heroin remain choices, as is shown by the 20% or so of patients who risk drinking on disulﬁram (35, 36) and the 35% of patients who test the opiate-blocking effects of naltrexone implants at least once (Steele, unpublished data). Secondly, disulﬁram or naltrexone are, in most cases, only a temporary aid to abstaining and can in practice be discontinued once patients have sufﬁcient skill and conﬁdence to cope regularly and predictably. In this context, disulﬁram and naltrexone act as trainers or facilitators whose presence is valuable during the initial learning process but is progressively less necessary as competence is consolidated. This is what happens in the treatment of resistant phobic or compulsive states, when therapist-assisted exposure and response-prevention may be necessary at ﬁrst (37). It is also what happens in driving lessons and other practical training courses. As we have previously mentioned, once a new pattern of behavior becomes automatic, routine or “normal,” it needs little reinforcement to be maintained. Once people have become reasonably ﬂuent in a new language, they do not usually need continuing tuition or exposure. Even if the new skill is not practiced for a few months, it will still be available if needed.
DEALING WITH “UNDERLYING PROBLEMS”
It is often assumed that alcohol or heroin abuse is usually (or, in some centers, always) because of underlying psychological problems and that any treatment that does not, from the start, address and relieve these problems is likely to fail. There are certainly some “dual diagnosis” patients with preexisting problems which would merit intervention even if they did not have alcohol or heroin problems as well. They may still need psychological and/or pharmacological help even if they become lastingly abstinent. However, “underlying problems” often turn out to be the result of excessive drinking (37–39) or of heroin abuse. Alternatively, they frequently reﬂect the sort of minor degrees of anxiety and unhappiness which many nonabusers also experience and which are not normally thought to require treatment. We suggest that in many cases, the difference between those who drown their sorrows and those who don’t is not that the former have bigger and better sorrows to drown. It is that— for various reasons—the former have got into the habit of drowning them while the latter have not. Good long-term outcome both implies and requires that the patient relinquishes this habit. Murphy and Hoffman (40) found that alcoholics who had successfully abstained for 18 months had “made a pronounced [cognitive] shift from ‘deprived users’ to ‘determined abstainers.’” They were “able to say, ‘well, that’s how I used to handle these problems, but no longer.’” The same probably applies to opiate addicts.
It does not matter much whether “alcoholism” implies daily consumption with physical dependence or binge drinking. The problem that all alcoholics have in common, as Lemere (41) pointed out, “is that they drink too much.” Accordingly, if their drinking stops, many “underlying problems” will diminish or disappear (42–44). This may explain why Azrin et al. (13) found to their apparent surprise that patients in stable relationships having supervised disulﬁram did very well whether they received intensive or minimal counseling.
Gournay (37), a behavioral psychotherapist, believes that “alcohol ... problems need to be managed ﬁrst. If disulﬁram is used, I would want to see the patient taking it and clearly demonstrating abstinence for three months before starting behavioral anxiety treatment. This is not only to give time for withdrawal symptoms to settle and to help the patient adjust, but also to see whether spontaneous remission might improve problems like anxiety and depression.” Miller and Hester (45) take a similar view. Problems that remain troublesome will clearly be much easier to treat if the patient remains sober during treatment.
Studies of factors which can interfere with foreign language learning show that anxiety is particularly important and that learning a new language is more anxiety-inducing than any other student course (46). In turn, “inadequate time-management skills [which] reduce the amount of time that foreign language learners have to study” may further increase anxiety (47). Anxiety can interfere with memory at three stages—input, processing and output. This means that the proportion of new information that remains in memory for later retrieval may be impaired. Anxious students were more likely to agree with statements on a rating scale such as “I may know the proper... expression but when I am nervous, it just won’t come out” (46). This may sound depressingly familiar to many professionals working in relapse-prevention and the solution, surely, is longer and more intensive practice. After all, even very anxious people who live in a foreign country for long enough do usually acquire reasonable ﬂuency in the host language, provided that they do not remain isolated in a linguistic ghetto. Disulﬁram and naltrexone can make it much easier even for anxious or depressed patients to learn or relearn the language of abstinence.
Incidentally, we want to stress that “abstinence,” in this context, refers to abstinence from drugs which have often caused problems to a particular patient. For patients to get used to not drinking alcohol or using heroin, they do not necessarily have to avoid the moderate use of other mood-altering drugs, though they should be warned against the risks of exchanging one drug problem for another. For example, patients who have been opiate-free in the real world for a year and have never had a problem with alcohol do not, in our view, need to be told that they should never risk enjoying a glass or two of wine or beer with their meals.
THE IMPORTANCE OF SUPERVISING DISULFIRAM AND NALTREXONE
All the controlled studies which have examined the issue have shown that involving a third party in supervising the administration of disulﬁram or of naltrexone is a crucial component of treatment (17, 15, 29, 48, Currie, unpublished data). A recent review of studies of supervised disulﬁram is summarized in Table I [please see Table I in the PDF version of this document].
Supervision maximizes the likelihood that if patients agree to take disulﬁram or naltrexone, it will actually get into their stomachs and stay there for long enough to be absorbed. This, in turn, maximizes the likelihood that the ability of disulﬁram (and of naltrexone) to “make it necessary for patients to deal with unpleasant feelings in a psychological [as opposed to a pharmacological] way” (37) will come into play. Reneging on an agreement to take disulﬁram or naltrexone under supervision amounts to a deliberate and public refusal to cooperate in treatment. Supervisors can be trained to deal with such attitudes which, at least in the case of disulﬁram, are usually not maintained (13).
The study by Fuller et al. (63) comparing therapeutic and subtherapeutic doses of unsupervised disulﬁram, strongly suggests that unsupervised disulﬁram is only taken regularly by the sort of compliant patients who would generally do well with almost any treatment that was acceptable to them. Though supervision may have a useful nonspeciﬁc symbolic effect, Chick et al. (58) showed that a supervised placebo is signiﬁcantly less effective than supervised disulﬁram.
Annis (33) has used calcium carbimide, which has similar alcohol-sensitizing effects to disulﬁram but is much shorter-acting (and no longer widely available). However, although clearly prescribed as part of an exposure and response-prevention approach, it was not supervised. Indeed, since it requires twice-daily dosage, it is much more difﬁcult to supervise than disulﬁram, which may only need to be given twice a week. This may partly explain why her results were much less impressive than those of Azrin et al. (13). As Onken et al. (64) note: “Although engagement, retention and compliance are problems for the treatment of virtually every medical and mental disorder, these issues are especially problematic for drug addiction treatment.”
Effective supervision requires the supervisor (whether a family member, friend, health professional, probation ofﬁcer or workmate) to be aware of the ways in which patients may try to avoid swallowing or retaining disulﬁram. Happily, these are few and easily thwarted (14, 65, 66). It is an important corollary that patients who both cannot resist the temptation to drink heavily and refuse to take supervised disulﬁram are to be generally regarded as not serious in their intentions to abstain from alcohol. Treatment can thus be refused or suspended with a clear conscience until they change their mind (4).
All these comments apply equally to naltrexone treatment for opiate abuse. In the randomized controlled trial by Gerra et al. (67) family involvement was an important component of the treatment program. The two groups given naltrexone did considerably and signiﬁcantly better in terms of abstinence and attendance than two control groups in a similar follow-up program without naltrexone. Stanton (68) stresses the importance and usefulness of recruiting family members into the therapeutic alliance and Galanter (69) routinely encourages the involvement of family members in supervising disulﬁram and naltrexone. Supervision of naltrexone was clearly a crucial component of the highly successful Singapore probation-linked treatment program (29) and of the similar study by Cornish et al. (32) already discussed. Length of treatment is clearly an important factor. In a 2.5-year follow-up study, Rounsaville et al. (70) noted that “Achieving abstinence from illicit opioids was associated with concurrent improvement in other aspects of functioning including reduction of criminal activity, improved medical status, improved social functioning, and reduced abuse of other psychoactive substances. However, many of these improvements were reversed immediately if relapse to opioid use occurred.” This may be especially relevant early in treatment. Hulse and Basso (71) showed that the level of supervision by family members at 6 weeks after detoxiﬁcation was signiﬁcantly related to remaining opiate-free at 6 months. Fortunately, supervision is now fast becoming a less important issue because effective depot or implant preparations of naltrexone have been developed which appear to block doses of heroin equivalent to 500 mg diacetylmorphine or more for at least 4 weeks and up to 6 months (72–77).
Disulﬁram does not readily lend itself to pharmacologically effective implantation but even pharmacologically inert implants of a deterrent drug can evidently have powerful psychological effects. Many patients are unwilling to risk a reaction by drinking alcohol (78) and they often report low or absent craving. With naltrexone implants, there is no risk of an aversive reaction if heroin is used and so, as previously noted, many patients make the experiment. This may be out of simple curiosity but it is often a response to craving. However, once patients realize that injecting heroin produces no effect, craving usually diminishes sharply. Since increasing numbers of patients know from the “addict grapevine” that naltrexone is an effective antagonist, many do not even test it out, even though after implantation, patients generally return to their usual environments and are exposed to typical opiate-using cues. Foster et al. (77) found that during the ﬁrst 5 days following detoxiﬁcation and NTX implantation, when residual withdrawal symptoms are particularly common, 30% of patients tested out the blockade with opiates and 37% used opiates during the period 5 days to 5 weeks postimplantation. However, only 33% of those who had used during the ﬁrst 5 days also used in the period 5 days to 5 weeks and only 3 of 15 patients who had tried opiates during the period 5 days to 5 weeks had relapsed at 12 weeks.
ANTAGONISTS TO OTHER DRUGS
Noting that speciﬁc monoclonal antibodies to digitalis had been developed to treat digitalis poisoning, Brewer (79) speculated that the same technology could be used to create antibodies to drugs of abuse. In the past few years, pharmacologists have developed monoclonal antibodies to cocaine, as well as a vaccine which enables the body to produce its own cocaine antibodies (80). Antagonists to nicotine and cannabis have also been developed. Alternative approaches include a “super enzyme” which reduces the effects of cocaine by speeding-up its metabolism. We may therefore soon have agents which will effectively block the effects or deter the consumption of most drugs of abuse. When that happens, the treatment principles described in this paper will apply to the management of substance abuse in general.
Supervised disulﬁram and supervised or implanted naltrexone create effective barriers to therapeutic ambivalence, truancy and apathy and thus facilitate the practice of nondrinking or nonopiate-using cognitive and behavioral responses. Sustained and realistic practicing of appropriate new responses—and, equally important, the sustained avoidance of old and inappropriate responses—improves performance and outcome in addiction treatment as it does in learning a foreign language. New antagonists may be equally effective in other types of drug abuse. It is important to recognize that although such drugs have real and useful pharmacological effects, their effectiveness is due as much to the long-term psychological consequences of these effects as to the effects themselves. This explains why the drugs can usually be discontinued with little risk of early relapse into old, maladaptive habits, once the new responses have become established and automatic.
It is not difﬁcult to suggest studies which would test this hypothesis. In the case of NTX, a randomized trial could compare outcome at 2 years in patients having oral NTX only, a single 6-week implant followed by oral NTX, a single 6-month implant followed by oral NTX, or two—or three—consecutive 6-month implants. Assuming similar levels of psychosocial support, we would predict different opiate-free outcomes for each group with the lowest levels in the oral-only group, followed by the 6-week and 6-month groups. (A nonrandomized study (81) comparing implanted and oral NTX already supports this prediction.) We would predict progressively smaller differences between the groups having two or three 6-month implants, on the basis that much of the necessary learning process would have taken place after 6 months of exposure and response-prevention. However, bearing in mind the previously noted ﬁndings of Murphy and Hoffman (40) we would expect 18 months of continuous blockade to give better results than 6 or 12 months.
For disulﬁram, comparisons could be made between groups offered supervised disulﬁram as one component of treatment (e.g., a community reinforcement program) for progressively longer periods—e.g., 1 month, 3 months, 6 months, and 12 months. As well as levels of use or avoidance of problematic substances, outcome should also include factors such as unemployment and crime, as well as the amount of counseling time needed. From the ﬁndings of Azrin (12), we would expect to ﬁnd lower levels for all three in direct relation to the length of treatment with supervised disulﬁram.In short, our hypothesis is that abstinence becomes easier with practice; that the longer and more uninterrupted the practice, the better; and that speciﬁc medications can facilitate this process. The idea is not a new one. As Hamlet says to Gertrude, (Act 3, Sc. 4.): “Refrain tonight, and that shall lend a kind of easiness to the next abstinence; the next more easy. For use almost can change the stamp of nature, and either curb the devil, or throw him out, with wondrous potency.” Or as an even earlier writer put it: “We become temperate by abstaining from indulgence and we are the better able to abstain from indulgence after we have become temperate” (82).