 Medication to treat addiction?The care and treatment of addiction in The Netherlands is being medicinalised. Will there be a pill for every form of addiction in the near future? Nowadays, there is a medicine for almost every physical or mental condition, disorder or problem, from a simple aspirin for headaches to sildafenil (Viagra) for erection problems.The pharmaceutical industry has never had such a large influence on our lives as it has now. This is also caused by the fact that the pharmaceutical industry would do anything to ensure a continuing optimalisation of its profits and, therefore, is forced to keep on searching for better and more effective medicines. For many people, taking medication has become the most natural thing to do. The large numbers of medicine addicts in The Netherlands, therefore, are not surprising. Judicial approach The addiction care also cannot escape from this urge for medication. On the contrary, many specialists in the area of addiction believe that the addiction care should have a more medical angle of incidence than it has had sofar. Until now, the addiction care has had a more psychosocial focus. The Netherlands provides a wide range of facilities for the treatment of drug, alcohol and gambling addicts. The number of professional care facilities continues to grow but the question remains whether everything should be labelled as being professional care. Addicts can receive help tailored to their needs, i.e. admission for one year or an occasional counselling session, help in taking care of practical matters, such as debts, et cetera, all these opportunities are available. In The Netherlands, addicts are generally considered to be people with a health problem, i.e. they are not primarily considered to be criminals. This view differs from the views of many other countries. Over the last years, however, The Netherlands is leaning towards a more judicial approach when it comes to the treatment of addiction. Biochemical approach The increasingly accepted biochemical approach to the problem of addiction defines addiction as a brain disease. If you want to combat a disease, you need medication. On July 7th 2000, the Evidence Based Addiction Research Foundation (EBAR) organised a conference about ‘The effectiveness of medication in treating drug addicts'. Among other things, EBAR aims to publish so-called evidence based research after what is effective in the area of addiction care. In this, the prescription of medicaments plays an increasingly important part. However, this has always been the case to a certain extent. For example, many people consider professional care to heroine addicts to be almost synonymous with methadone supply. Experiments The aim of the conference was to present research after the scientific effectiveness of four medicines, i.e. methadone, LAAM, buprenorphine and naltrexone. Not only an overview was given of all initiatives in this area but also the trends in the treatment of drug addicts were discussed. Most research after the above-mentioned substances takes place in the United States, i.e. about eighty per cent of all international research in this area is being conducted in the US. All the research is being done through the American National Institute for Drug Abuse (NIDA). There has only been a limited number of experiments with other medicaments than methadone in the Netherlands. "There have only been a few projects with other medication that methadone in the past years," doctorandus Fons Kok says, addiction inspector for the Dutch Ministry of Health, Welfare and Sports and chairman of the conference. "In the Dutch addiction treatment system, the provision of methadone plays a dominant part." The number of addicts participating in the methadone supply has almost doubled since 1988: from 6,500 to about 12,000. However, this supply was not very innovative. In contrast to the United States, in the Netherlands there are no formal guidelines for the methadone programs which at least should be seen as an omission after thirty years of methadone supply. For this reason, Kok called for a revitalisation of the debate on our position as to methadone but also to be open for other options. Furthermore, Kok argued for a broadening of the pharmaceutical training of doctors. Doctor Peter Geerlings, medical director of the Jellinek Clinic, agreed with Kok. "Prescribing addiction medicaments is a physician's responsibility but he must have basic knowledge of their effects and never shift his responsibility upon another." Other options Other medicinal options for the treatment of heroin addiction were discussed in the lectures given by four American researchers. They informed those present, mainly physicians, psychiatrists and (clinical) psychologists, about the proven effectiveness of the applied substances, which substance was suitable for which addict, who should supply the substance, whether the substance in question does not conflict with other substances that may be taken and how rules and regulations could be carefully followed. Dr Frank Vocci, director of the Treatment, Research & Development department of NIDA, discussed the research findings of methadone. "Methadone is not suitable for curing addiction but only for controlling it," he said. However, research shows that in the US methadone prescription has lead to a decrease of the number of heroin overdoses, a reduction of heroin and cocaine use as well to a reduction of syringe exchange and an increase of the number of addicts staying in treatment. According to Vocci, "methadone prescription is most effective when it is combined with extensive psychosocial professional care." Substitute for heroin Dr Richard Rawson of the UCLA discussed the substance LAAM as a substitute for heroin. In his lecture, he mainly mentioned the advantages of this substance in comparison with methadone. Just as methadone, it has a sedative effect. However, this effect lasts much longer, i.e. about three days. Patients seemed to feel better and were allowed to lead lives less tied to the clinic due to LAAM's three-days-a-week dosing schedule than would have been possible with methadone's daily dosing. Here, abstinence, i.e. becoming drug-free, is also not a goal, however. Dr Walter Ling, also of the UCLA, described buprenorphine which is officially registered in the US as fit for the treatment of drug addiction but not in the Netherlands. This research shows that the substance is safe and does not create feelings of euphoria. Also, buprenorphine does not cause much dependence and causes no withdrawal symptoms. The reviewer Dr Joost Vrasdonck, psychiatrist at the Brijder Foundation in Alkmaar, regretted that buprenorphine cannot be used for the care and treatment of addicts in the Netherlands: "It is beyond belief that such an important medicine that can serve as a substitute for methadone is not available in the Netherlands." Stabilization or detoxification The medicines that were discussed during the EBAR conference only applied to the treatment of heroin addiction. No attention was paid to other forms of drug addiction. Also in those areas, however, extensive research is being conducted after substitute medication. The question remains whether the current developments in addiction care do not have an overly medicinal focus. The EBAR Foundation recognises that medication for the treatment of addiction is an important factor in the addiction care but adds to this that medication is most beneficial when combined with drug counselling and behavioural therapy. "I am not against the use of medicines if they are being used as a therapeutic means," Teun Stortenbeker, general director of De Hoop, says. "However, what does concern me is that the nature of the future addiction care will be largely determined by physicians and that the addiction care will be medicinalised. There is undoubtedly a need for physicians but physicians are no professional care workers. Physicians have a medical responsibility whereas professional care workers have a psychosocial one. In taking on the problem of addiction, professional care workers can go much further than physicians. Furthermore, I believe that addiction is primarily not a substance problem but a psychosocial problem, which in time could be accompanied by medical problems. The current stage of the addiction care resembles the development we have seen in psychiatry. Also in that area, there used to be a strong social focus but later there was much more attention for concrete therapeutic treatment. Currently, the area of psychiatry is highly medicinalised and the main approach towards handling psychiatric problems consists of prescribing medicines." Clear goals De Hoop is not completely against the prescription of medicines for the treatment of addiction. However, the goal of this prescription should be clear. Several years ago, De Hoop gained experience in the area of medicinal detoxification. De Hoop conducted an experiment with several clients to let them undergo detoxification under the anaesthetic. Its explicit aim was physical detoxification. The experiences were positive. Currently, a large-scale research after this detoxification method is being conducted in the Netherlands. Stortenbeker: "With the treatment method of detoxification under the anaesthetic medicines are also used to make people become physically clean eventually. If medicines are used that way, I amnot against it." However, Stortenbeker is apprehensive of a similar development as happened with the prescription of methadone. The original aim was abstinence but eventually the substance was almost exclusively supplied on the basis of maintenance and the stabilization of the addiction. If that is the ultimate goal of the treatment, De Hoop continues to fight against it. Stortenbeker indicates that it is possible within a therapeutic setting based on round-the-clock treatment to work on a life without addiction and substitute medication. "However, this does require the addict's willingness to fight for such a life. I realise that the situation within this setting obviously differs from society. Still, our society has an enormous need for workers. In my opinion, we just cannot maintain people's addiction by supplying substitute medication and denying them the opportunity to fully participate in the labour process." Published in De Hoop Magazine, no. 4, 2000 |
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