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Published online by Cambridge University Press: 02 January 2018
Summary Treatment of illicit drug dependence typically involves a combination of pharmacotherapy and psychosocial interventions. Efficacy research supports methadone maintenance in opiate dependence. There is less evidence to support the use of buprenorphine (an opiate receptor partial agonist), lofexidine (an 〈2- adrenoreceptor agonist) and naltrexone (an opiate receptor antagonist). Evidence for the effectiveness of detoxification, which is one of the most widely used treatments, is poor. Of the psychosocial interventions, reasonable evidence exists for the effectiveness of motivational interviewing. Other psychosocial treatments have rarely been compared with no or minimal contact conditions in randomised trials, and their reported effectiveness is often weak. Residential treatments are not demonstrably more effective than community programmes.
Substance dependence, or ‘addiction’, is diagnosed taking several factors into consideration (Box 1.1). Substance misuse refers to the non-therapeutic use of drugs in a manner that is potentially harmful, but does not meet criteria for dependence.
Many trials report significant benefits of addiction treatments (National Consensus Development Panel, 1998), and guidelines for drug addiction treatment have been published by the Department of Health (1999). However, only 20% of participants report abstinence from all illicit substances for at least 1 year, despite receiving treatment. Furthermore, drop-out rates of nearly 50% are common. It is notable that only half of patients with other chronic disorders (such as hypertension or diabetes) fully adhere to medication schedules, and high drop-out rates are common with many forms of psychotherapy.
Box 1.1 Diagnostic features for substance dependence
• Three or more of the following should have been present in the previous year:
• a compulsion to take the substance
• escalation of amount used
• a withdrawal syndrome following reduction in use
• tolerance
• neglect of other activities in favour of substance use (salience)
• persistent use despite evidence of harm
Trials of treatment for drug addiction are liable to all the common methodological flaws seen in clinical trials in psychiatry, including failure to use intention-to-treat analysis, failure to randomise results, lack of sociodemographically matched control groups and confounding due to unplanned variations in contact with treatment services. A US government report concluded that ‘results derived from self-selected patients who remain in treatment optimistically skew findings in favour of effectiveness’ (National Research Council, 2002).
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