Section VIII General Observations Concerning Treatment

We discussed the various approaches to treatment or management of the adverse effects of non-medical drug use in considerable detail in our Treatment Report. We do not propose in this report to go over all the ground that was covered in the previous report nor even to attempt to summarize what was said at that time. There are, however, certain matters that require further commentary because of their general importance for social policy, and in some cases because of developments that have taken place since the Treatment Report. It is also necessary in this report to keep before us a realistic appreciation of the general outlook for the treatment of adverse drug effects, and in particular for the treatment of drug dependence. An understanding of what we may reasonably expect from treatment has an important bearing on the priorities which we assign to other kinds of intervention.

Some critics of the Treatment Report complained that we were too pessimistic about the outlook for treatment. It was certainly not our purpose to be unduly pessimistic or to underestimate the efficacy of various methods of treatment. It was our purpose, however, to avoid creating unjustified expectations for treatment. We believe that more harm can come from excessive optimism than from excessive pessimism in this area. The obvious danger of excessive optimism or exaggerated claims of success is that people may be misled into thinking that there is a means of repairing the damage if dependence or other serious chronic effects result from experimentation with certain drugs. Their is reason to believe, for example, that there has been widespread misunderstanding that methadone maintenance is a "cure" for opiate dependence, when in fact it merely alters the form of such dependence. On the whole, we found the outlook for treatment, particularly of drug dependence, to be a discouraging one. We felt it essential that this fact be clearly presented so that people might appreciate the serious risk of long-term problems resulting from experimentation with dependence-producing drugs, and so that the importance of efforts at prevention should be placed in proper perspective. It was not our intention to disparage or discourage the efforts to improve existing methods of treatment and to discover new and more effective ones. We must continue to give those who are engaged in treatment all the support they deserve, but at the same time we must have realistic expectations concerning success and reasonable criteria of progress in this most difficult field of activity that is so full of frustrations and disappointments. In the long run, such limited expectations and criteria of success will do more to encourage treatment personnel to persist with the task than the disillusionment and abandonment of constructive efforts that so often follows on unrealistic expectations and standards.

In appraising the general outlook for treatment a distinction must, of course, be made between the treatment of acute or short-term physical and mental effects, and the treatment of dependence. On the whole, available treatment methods are able to cope quite effectively with short-term effects, and with many of the consequences of chronic drug use. It is in the treatment of dependence that the major difficulty lies. The various approaches to the treatment or management of dependence include the following: efforts to achieve abstinence or "cure"; maintenance, which involves the continuation of a form of drug dependence; the use of antagonists or substances which block the action of a dependence-producing drug without themselves producing significant dependence; the use of substances which produce an adverse or unpleasant reaction when the dependence-producing drug is used; and, more recently, the possibility of active immunization against the dependence-producing properties of a drug.

It is generally acknowledged that the various approaches to achieving abstinence or cure have a disappointingly low rate of success. Some appear to be more successful than others, but the best can only reach a very small proportion of the drug-dependent population. Among the most successful has been Alcoholics Anonymous in assisting alcoholics to achieve abstinence. For one reason or another there has not yet been comparable success with the same approach in the treatment of opiate dependence. Former opiate-dependent persons have been employed to a considerable extent in treatment, but they do not appear to have been able to achieve success on anything like the scale of Alcoholics Anonymous. If anything, the short-term outlook for the cure of 'speed' or intravenous amphetamine dependence is even more discouraging than in the case of opiate dependence, although there are suggestions that very heavy 'speed' use may be a transient phase and some 'maturing out' may occur after a few years with most individuals. Efforts to promote abstinence in drug-dependent individuals by long periods of confinement in prison or hospital settings have yielded poor results in the long run. The effectiveness of individual psychotherapy in the treatment of drug dependence has not been adequately demonstrated, and in any event, it is prohibitively expensive, and there are not enough therapists for the task. Group therapy, and in particular the encounter technique of the rigorous therapeutic community, has had some encouraging results, but they affect only a comparatively small proportion of the drug-dependent population. However, because of the relative importance of this form of treatment among those directed to abstinence or cure, we comment on it in greater detail in subsequent sections. There has not yet been a serious effort to achieve the potential of what is sometimes referred to as the "one-to-one" approach—the various forms of personal support and practical assistance given by a dedicated person to the drug-dependent person to help him or her to find a new basis for life. We shall have more to say about the importance of this approach in a later section.

Opiate maintenance, or the substitution of one dependence-producing drug for another, is discussed in detail in the following section. The increasing recognition that it holds out the best hope for management of opiate dependence is a reflection of the great difficulty of achieving abstinence or cure. Maintenance is generally not spoken of with respect to other forms of drug dependence, although there are undoubtedly many cases of persons who have become dependent on other drugs, such as the barbiturates, and are maintained on such drugs as a form of medical treatment. Maintenance would not appear to be practical as a means of managing amphetamine or 'speed' dependence because of the difficulty of stabilizing doses at levels which do not cause significant disruption of normal physical or mental function. Such maintenance was apparently tried at one time in Sweden, with disastrous results. Basically, maintenance involves the decision as to whether, on balance, there is sufficient benefit to be gained from it to justify the risks necessarily involved in making a dependence-producing drug legally available for the management of dependence.

Therapeutic techniques employing the use of antagonists in the treatment or management of opiate narcotic dependence have not yet been fully developed. There are various drawbacks to existing antagonists, often including unpleasant side effects and a short duration of action. More adequate antagonists are in various stages of development and testing. It is assumed that it will be possible to develop a satisfactory antagonist that can be given orally at intervals of several days, or implanted in the body and gradually released into the blood stream, providing opiate blockade over a long period of time. However, antagonists do not eliminate the craving for opiate narcotics in dependent users, nor do they deal effectively with the tension or depression from which many users seek relief. Consequently, even if satisfactory antagonists are made available for the management of dependence, they are likely to be willingly accepted by only a small proportion of the opiate-dependent population. As yet there are no generally adequate antagonists for the other major drugs of dependence, such as alcohol, barbiturates, amphetamines and tobacco, although significant research is currently being conducted in some of these areas. Antabuse® (disulfiram) does not block alcohol effects, but inhibits the use of alcohol by producing very unpleasant toxic interactions when the two drugs are taken simultaneously. Although Antabuse®, when administered chronically or implanted, reduces alcohol consumption, such treatment is acceptable to only a very small proportion of the alcohol-dependent population.

In our Treatment Report, we recommended that research on the development of an effective antagonist for amphetamines be encouraged. The suggestion met with some unfavourable reaction on the ground that because of the likely mechanisms of action of amphetamine in the brain, and its similarity to natural body hormones such as adrenalin, an effective amphetamine antagonist would interfere significantly with the normal functioning of the nervous system. Although this may be a likely possibility, because of the present uncertainty as to the actual mechanisms by which amphetamine produces the effects which reinforce or reward its use in humans, we felt that the development of a satisfactory antagonist which might reduce amphetamine self-administration could not be ruled out a priori. Since our Treatment Report, significant advances have been made in this area. In Sweden, a compound is currently being investigated which significantly reduces the reinforcing effects of oral and intravenous amphetamine use. Available data, although limited, suggest no serious side effects or interference with normal physiological and psychological function. For further details, the reader is referred to Appendix A.3 Amphetamines and Amphetamine-Like Drugs and Their Effects.

There is a significant possibility of developing techniques for the active immunization of persons against the effects of various drugs. This would produce a drug-neutralizing effect similar to that of a chemical antagonist, although the effect would result from a different biological process. Employing antibodies originally developed for drug analysis (immunoassay), active immunization in animals has met with some success in reducing drug reaction, but it has not yet been tried in humans. There is the potential drawback, however, that such immunization might be irreversible. In the case of opiate narcotics, effective immunization (or long-acting chemical antagonists) would likely deprive the treated person of the medical use of opiate narcotics, as in the relief of severe pain. With amphetamine immunization, there could be complications arising from the similarity between amphetamine, adrenalin, and related hormones, as noted above.

Even if satisfactory techniques were developed for the neutralization or blockade of the major dependence-producing drugs, the overall impact of such treatment on multiple drug use might be disappointingly limited. The number of psychotropic drugs available is vast. Even within general pharmacological classes, there is often significant variability in chemical structure and in the mechanisms of action of different drugs. Specific antagonists would not be uniformly effective against all drugs. Consequently, the elimination of the use of one substance might do little more than change the form of dependence or the drug used. Taking the antagonist approach to an extreme, multi-drug use would ultimately require multi-antagonist treatment, which would be clearly impractical. Consequently, it is likely that antagonist treatment will be of limited value, except to certain persons seeking this type of assistance.

A significant change in non-medical drug use which may be included in a broad concept of "treatment" is elimination or reduction of use brought about by recourse to various forms of self-control, inspiration, meditation and involvement in other interests. These were discussed to some extent in our Treatment Report, in the Appendix entitled Some Other Therapeutic Approaches. These approaches, although often strikingly effective in individual cases, depend so much on particular circumstances, including the personality of the subject and the other persons from whom he derives assistance, that it is difficult to generalize about their efficacy.

Certain pharmacological issues relevant to treatment are discussed further in Appendix A The Drugs and Their Effects.

In conclusion, a word should be said about treatment capacity, or the adequacy of existing facilities for treatment in Canada. In our Treatment Report we made recommendations for a community-based network of treatment and rehabilitation services, and in Appendix H Treatment Capacity in the Provinces we have attempted to convey some idea of existing facilities for methadone maintenance, treatment in therapeutic communities, and treatment in general and allied special hospitals. It is our overall impression that Canada still lacks sufficient treatment facilities of various kinds to meet the real and potential need of its drug-affected population. We have not made a detailed survey of facilities for the treatment of alcoholism, but there is reason to believe that they fall well below the need for such treatment. In several cases, reports suggest that existing treatment facilities are operating at under-capacity. This would appear to be true, for example, of some of the methadone programs and the residential therapeutic communities. In many of these cases, however, this is probably due to limitations of staff, or to failure to exert sufficient "out-reach" to make patients aware of available treatment and to attract them into it. Regardless of physical accommodation, the effective capacity of treatment programs is limited by the number of qualified staff. There is a need to attract many more persons into the treatment of drug-related conditions and to provide the necessary training for them. We have further occasion to discuss the need for increased government initiative and support in developing treatment facilities and attracting drug-dependent persons into treatment in subsequent sections.