The concept of self-medication in the addictions:
Implications for a model of clinical management within a secondary care service
Gianni Dianin

ABSTRACT

The split between primary and secondary care in the addiction field has brought about a redefinition of the way patient care is planned and in. the way addiction services interface with and complement each other.

In the addiction field this strategic re-configuration has far reaching implications for the organisational, managerial and the clinical level.

In this context the role of the Drug Dependency Unit becomes redefined as a Specialist Service whose main function is to offer a service to those problematic drug users whose needs could not be adequately met in the community at primary level, because of comorbidity and/or chronic polydrug use.

Within this framework the concept of drug use as self-medication has been found to provide a useful tool in the treatment of the secondary care sector clients group.

The advantages in employing such conceptualisation are related to a better differentiation of the caseload, an increased efficiency in devising the treatment plan, and finally in a better co-operation between primary and secondary care services.

This paper will describe the development of a secondary service, St. Clement's SDU. Finally the implication for research are considered.

THE DDU ROLE AND HARM REDUCTION

Historically the DDUs role was to provide pharmacological maintenance, in-patient detox or psychiatric treatment, to those who had already failed to become drug free in the primary services.

Recently the DDUs have assumed more of a specialist treatment role within the present configuration of drug services .(ie primary/ secondary/ tertiary tiers of treatment).

The role of the DDU has become therefore to offer a service to those so called "problematic drug users" who had already failed to comply with their treatment plan at primary level.

However in a climate of heavy cuts to the Health budgets, the limited resources of the DDU are almost completely used to provide the maintenance service rather than a specialist one. This is because maintenance services are seen as "Specialist", and theoretically no primary service should provide maintenance.

This results in a situation whereby the DDU just accumulates people on maintenance prescriptions, without having the possibility to refer them back to the primary services once stabilised.

One way to use better the D'DU resources would be to understand that maintenance treatment per se, like drug use per se is not pathological. So the resources of the DDU could be directed more effectively where they are most needed, that is where there is evidence of drug related pathology either physical or psychological,

At the Specialist Drug Unit (SDU) the DDU of Tower Hamlet, the staff has been experiencing the fact that many of its clients are now stabilised and could be managed in the community.

The client group the SDU should be actively targeting are those drug users who are unable to stabilise even on a maintenance prescription, or who have acute conditions which needs specialist care.

This paper will be concerned with the theory and practice related to those clients who, because of psychological difficulties, are not able to stabilise.

In particular this paper , using the concept of "Self-Medication", and Psychotic- non Psychotic continuum, will try to provide a therapeutic model of intervention for client with dual diagnosis, which now represent at least 30 per cent of the caseload.

SELF-MEDICATION and DUAL DIAGNOSIS

The concept of Self-medication goes back to the 1960s with Psychoanalysis. H. Rosenfeld in his influential book "Psychotic States" :introduces two papers on drug abuse. In these paper drug abuse is seen as a self-:medication: The drug users would use drugs as a manic defence from his/her psychotic suffering.

Drug abuse in the 60s was still seen as the symptoms of a deep psychopathology and considering that at the time the prevalence of drug abuse was just a few hundreds it is possible to assume that there was not enough experience in the drug field to know that drug use is infact not necessarily a sign of psychopathology.

Also mental illness was always, and still is unfortunately, seen as the result of drug abuse.

We now know that about 50 per cent of lifetime drug dependent people also had a lifetime psychiatric disorder. (Kessler 1994)

This means that a significant percentage of our client group is likely to need a service able to address such comorbidity at a specialist level and not just by referring to psychiatric services but by having staff trained in dealing with comorbidity from within the DDU.

DIFFERENTIATION OF CLIENTS NEEDS

After about 15 years of harm minimisation it seems obvious that it is possible to use drugs in a reasonably healthy way without having to destroy one's life, relationships, career.

One easy differentiation can be between the adolescent who uses recreationally at week-ends, and the polydrug user who is dependent, on several substances and seems to be unable to stabilise. However there is no clinical tool to help the clinician in making a differentiation which goes beyond the quantity of drug used and the psychosocial difficulties related to the abuse. (ie Addiction severity index).

For example one of the clients at the SDU, John 32 years old, was referred by his GP for his intractable drug problem which had created all this person problems. He had already failed 3 detoxes and until he was not drug free he could not have hoped to do anything with his life. But looking at John's history it cames out that he never knew whom his father was, his mother had a lifetime manic-depressive psychosis, and the brother was in prison for robbery. Also he has no qualifications, and was never able to hold down a job. At the age of 5, John was taken into care for neglect, and there he was bullied, and raped by the older boys. When at the age of 15 he left the Care home, he started to prostitute himself, and at 16 he was already using Heroin. The last time John attempted to detox he had a severe depression with suicidal ideations. Hence the referral to the SDU.

Unfortunately this case is not rare and a significant number of clients present with this kin of deprived and abused childhood.

It is therefore possible to hypothesize that John's drug use is based on an attempt to minimise internal impulses of a psychotic nature. This type of abuse is therefore self-medication, and it seems useless to attempt further detoxes without taking into account this person internal psychological resources.

So, in order to make the intervention more effective it is necessary to operate a distinction not only between frequency and quantity of drug abuse and its related problems, but above all it is imperative to assess whether the dynamics linked to the abuse have to do with selfmedication.

One way to differentiate the quality of drug use is to use a continuum between psychotic and non-psychotic use.

Psychotic and non-psychotic personality is not a psychiatric diagnosis, but is a terminology used by Dr. W.Bion, a Psychoanalyst. Dr Bion used this terms to understand how to engage, stimulate, the non-psychotic part of the person, in order to increase the person's internal resources and insight.

To clarify, the terms are not psychiatric, and are non judgemental or labelling, because they are applicable to every one of us, as we all have a psychotic and a non-psychotic part of our personality.

There would be no use in labelling clients already discriminated because of supposed selfinflicted problems.

NEUROBIOLOGY AND SELF-MEDICATION

There is evidence from neurobiological studies that drug use is affected, by the way our endogenous opiate system works. Research done on animals show that the environment, genetic factors, and emotional factors do affect the self-administration of opiates.

It is possible to hypothesise that an individual, for genetic, environmental, perinatal or emotional factors, may have such a dysfunction on his/her endogenous opiate system to induce the person to use the drugs that will be able to re-balance the neurochemical dysfunction, and bring about emotional relief.

TREATMENT IMPLICATIONS

In order to respond to the needs of the client with dual diagnosis it is necessary to have a clear clinical protocol.

At the SDU all clients receive a nurses assessment. When a dual diagnosis is identified the person will be then referred both to the Psychiatrist and to a Psychotherapist who will then liaise regarding the treatment plan, which will include Pharmacotherapy and Psychotherapy.

The nursing staff will also arrange the practical support the client may need.

The fact a Psychotherapist is involved has created some difficulties with the fact that there is still little knowledge of the difference between Advice, Counselling and Psychotherapy.

In the drug field unfortunately, psychological therapies have always been given little space. What the clients are able to receive in the drug service is "Drug Counselling", which is practised by anyone even without formal. qualifications. This is something that at the level of a DDU should be addressed, as complex clients such as those with dual diagnosis deserve to be offered a Specialist psychological intervention, as opposed to a generic one.

CONCLUSIONS

Starting from the role of the DDU this paper has tried to address the needs of clients with dual diagnosis.

In an harm minimisation environment, the concept of self-medication and of the Psychotic non-psychotic continuum has been used at the SDU to assess and provide treatment for the clients with dual diagnosis.

Given the limited resources available in the drug field to-day and the great demand put upon staff by the complexity of the clients' :problems, there is an urgent need to reconfigure services in the light of such considerations.

The drug problem becomes therefore secondary and the whole individual needs becomes more important. The medical model used in the DDU to-day is restrictive and in a way colludes with the clients irrational belief that everything is due to drugs and can only be treated with drugs.

The DDU should be able to provide the Medication needed, but should above all be able to address the causes of the self destructive use displayed by dual diagnosis client.

In conclusion, differentiating the client group will not only make a better use of our scarce resources, but will also respond adequately to the clients needs.

REFERENCES

1) H. Rosenfeld (1960) "On Drug Addiction"; and (1964) " The pathology of Alcoholism and Drug addiction: A critical review of the psychoanalytic literature". Both From: "Psychotic States" (1965). Karnac. London.

2) Pfeffer and Waldon. (1987) "Psychiatric differential diagnosis" London

3) Strang J.; Gossop M. Ed. (1994) "Heroin Addiction and drug policy: The British System". Oxford.

4) Bion. (1967) "Second Thoughts;Differentiation between the psychotic and non-psychotic personalities". Karnac. London.

5) Dworkin, Porrino and Smith. (1993) "Neurological substrates of Opioid abuse" Chapter 13 in "The neurology of opiates" R. Hammer Ed.CRC press USA.

6) Mirin S.,Weiss R. (1991) Chap.12 "Clinical Textbook of Addictive disorders" Ed. Frances R., Miller S. The guilford Press; New York, London.

7) Dodes M.; Khantzian E. (1991) Chap. 17 in " Clinical TextbooK of Addictive Disorders". Ed. Frances & Miller. The Guilford Press.

8) Kessler R.; (1995) Chap.7 in "Textbook in Psychiatric epidemiology" Ed. Tsuang, Tohen & Zahner. Wiley-Liss Inc.