Abstinence – treatment, philosophy, methods
In a second part article Dr Gordon Morse tackles detoxification as a route to abstinence, putting a relevant focus on the individual, philosophical or even spiritual meaning for the patient.
His view, that it is the individual’s confidence and approach, the significance given to their endeavour, rather than method per se, which is central in successful preparation, aftercare and outcome. Ed. (Part 2 continued from Network issue16)
In the last article I gave some of the background against which drug users will ask us to help them achieve abstinence: the time to rid ones self, once and for all from dependency on drugs, doctors, pharmacists and services, and the (very real) daily fear of having any of these withdrawn.
Perhaps the first thing that the doctor will consider, and the patient will worry about, is the chemical process of detox. I will talk a little about detox later, but I am not going to spend much time discussing it – after overseeing many thousands of detoxes I am firmly of the opinion that the method of detox has very little bearing on the success or failure of achieving durable abstinence.
“ . . . it is very often the narrowest (and most puritanical) sense of abstinence, namely from ALL mind affecting substances, which affords the easiest route.”
Preparation for abstinence begins with the debate about what abstinence actually is.
- Is it to be (at its simplest) abstinence from heroin, but continue on methadone?
- Or abstinence from all drugs but allow occasional alcohol?
- And maybe allow cannabis as well?
- Or maybe leave off all illegal drugs and alcohol, but cigarettes and caffeine are OK?
All of these paths can be adopted and are achieved with varying degrees of success, but perhaps paradoxically, it is very often the narrowest (and most puritanical) sense of abstinence, namely from ALL mind affecting substances, which affords the easiest route.
Why is this? Well, at the very least, it is the simplest. It avoids all those judgement calls about what drug is all right and what isn’t, when it is all right, how much is all right and so forth – it is completely black and white.
“This is as much a spiritual journey as anything else – and that is not to confuse it with a religious state as some of the abstinence-knockers would like to do.”
And it avoids leaving another addictive avenue to be exploited when one is closed, as frequently can happen with alcohol when opiates are stopped.
And setting the hurdle high sets the prize for achieving it high as well: this is a life saving process where the reward of life is used in its fullest sense – in both quantity and quality. It is an admission that although drug use may have been nice, and maybe others can get away with it, for me, I just can’t do it any more.
And by being so black and white, so it identifies a person: how often our patients are identified as “drug addicts” – as if that defines and explains everything about them. Rather like shedding the pupa’s case, so the recovering addict can metamorphose and re-identify himself as abstinent.
This is as much a spiritual journey as anything else – and that is not to confuse it with a religious state as some of the abstinence-knockers would like to do. It can be religious if that works for you – certainly many world faiths embrace abstinence from Methodists to Muslims – but it can be as simple as respect for ones own health and sanity, and the health and sanity of those around us.
Preparation also (vitally) includes education about relapse on loss of opiate tolerance, education on the detox process itself, educating the “significant others” in the person’s life to support them through the detox process and the weeks and months that follow, and so forth.
So what of aftercare? Stanton Peele says that all you need do is give them a home and give them a job. William Miller (after Gorsky’s work) says that relapse can be avoided in 80% of cases if you deal with their isolation and demoralisation.
Then there are psychological therapies such as Marlatt’s CBT Relapse prevention model, group therapies that addresses interpersonal skills, and drugs such as naltrexone and antidepressants.
And of course there are support groups, rehabilitation centres and the 12 Step Fellowships of Narcotics Anonymous, Cocaine Anonymous. Alcoholics Anonymous and others.
All of these models are invaluable for some and useless to others. Indeed we know that many people achieve durable abstinence with no help from anyone – they just get fed up and get on with it. As GP’s we have a good understanding of our patients as people – we have often known them for a long time and can help them make some of these choices about which path to take and what support might fit in with their individual philosophies.
I have left detox to the end of this piece, because it is lowest in terms of importance.
Detox from opiates is all about confidence – it is seldom dangerous. There are all manner of detox methods out there: probably the most popular is a slow weaning off methadone over whatever period the patient dictates. Intuitively that seems the easiest, but I am inclined to doubt it. These very slow reductions span periods that frequently stretch motivation beyond its limit, and I have never seen anyone stop smoking by cutting down, cigarette by cigarette, over weeks or months. And the end of these weanings, as every golden milligram is chipped away, seem to be coloured by severe withdrawals the intensity of which follows no physiological logic whatever.
It is true that many achieve their abstinence this way, but I suspect that is because tradition has made this the overwhelmingly most popular detox method.
No, I am inclined toward the “grasp the nettle” detox over a couple of weeks or so when the patient is at their motivational zenith, and accompanied by as much intensive support as possible.
There are various chemical regimen that can aid this process which are to be found in the literature, and for the sake of space, I will leave there for now.
Because abstinence is about everything other than detox: In Abstinence there is something redemptive in it that allows the individual to leave the chaos, pain and shame behind, and start their life again. And that is all about philosophy, not pharmacology.
With thanks to Brahms, whose “German Requiem” was playing as I wrote this. (A Requiem reflects on a past life whilst welcoming the next – and Brahms was an atheist)
Dr Gordon Morse GP Medical Consultant to Clouds House, Trust Specialist and Lead GP Clinician for West Wiltshire Specialist Drug and Alcohol Service, RCGP Regional Lead. From – NETWORK 17 APRIL 2007
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