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Harm Reduction for Substance Abuse in the Psychiatric Setting
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by Mark Willenbring, M.D.
Psychiatric Times February 2000 Vol. XVII Issue 2
Psychiatrists are frequently presented with patients whose substance use is either harmful or could become so, but who refuse a referral for substance abuse evaluation or treatment or do not respond to available programs. Often these patients require treatment for co-existing psychiatric disorders, and many are seriously ill. Alcohol and drug users may present with intoxication or withdrawal, and they are at higher risk for depression, toxic psychosis, suicide and violent behavior, delirium, infectious diseases such as HIV infection and hepatitis, and many medical complications of heavy drinking. Although psychiatric training prepares physicians for diagnosing and treating co-existing psychiatric conditions, training in the management of addictive disorders is often inadequate. Consequently, many of us feel unprepared to manage the addictive disorder itself, especially in the context of general psychiatric practice.
Barriers to Management
Over the past 30 years, treatment for uncomplicated substance use disorders has become well-established. Movie stars, politicians and sports figures frequently talk about their treatments at high-profile treatment programs, enhancing public acceptance and awareness. Once identified, patients often accept referral, successfully complete treatment and remain in remission. One characteristic of uncomplicated substance use disorders is that they have a relatively high rate of complete remission in comparison to other psychiatric disorders. Unfortunately, the addiction treatment system and the mental health care system are independent of one another, and funding flows in separate streams. Psychiatrists find it difficult to obtain reimbursement for treating addictive disorders and are seldom invited into the addiction treatment network.
Furthermore, there are many potential barriers to successful identification and referral. Although psychiatrists are better than other physicians at identifying addictive disorders, we still miss too many cases or fail to address them, falsely believing that treating the other psychiatric disorders will lead to cessation of substance use. Even after successful identification, many patients refuse referral for addiction treatment, but still need psychiatric treatment. Even when patients do accept a referral, addiction treatment may be partly or wholly unsuccessful, as in cases where substance use continues when the patient returns to the referring psychiatrist. Finally, although programs that fully integrate psychiatric and addiction treatment are becoming more common, they are still unavailable in many areas. Moreover, the most well-known model is based on assertive community treatment for severe and persistent mental illness (RachBeisel et al., 1999). Many dual-disorder patients who have addictive disorders unresponsive to conventional treatments would not be appropriate for such programs.
Until recently, models for addressing persistent addiction in the context of psychiatric practice have not been available. In fact, providing psychiatric treatment in the face of continuing substance use might be criticized as enabling. According to the dogma of some treatment systems, psychiatric treatment should be withheld until the addicted person reaches bottom, thereby becoming ready to change. There is no evidence, however, that such an absolutist approach is effective or even not harmful. Additionally, taking this stance is not ethically defensible in many cases. The intense public debate and ambivalence about drug abuse and drug policy has intensified and politicized this question, making it even more difficult to confront and resolve.
Harm Reduction Strategies
Gradually, over the past few years, a new model for the management of active substance use disorders has been taking form. Although newly applied to addictive disorders, this model is not really new to psychiatry or medicine. It is based on the time-honored principles of palliative care, where palliative is taken in its broad sense of relieving, alleviating or easing a condition without curing. It does not refer exclusively to care for terminal conditions. Taken this way, most psychiatric treatment is palliative, and non-curative care for chronic conditions is something most psychiatrists are both skilled and comfortable in providing. The general principles of palliative care, as they are applied to other chronic illnesses, are familiar (Table 1). Applying these principles to addictive disorders is less obvious. To do so requires a new conceptualization of addiction, the goals of treatment and the methods to achieve these goals.
Addiction has many characteristics of a chronic illness. It has remissions and relapses, its course is highly variable, and its severity varies from very mild and transient to severe and persistent. Patients with different types and severity of substance use disorders respond to different interventions. Substance abuse and dependence are often disorders of adolescence and early adulthood, and most occurrences are mild to moderate and self-limiting. While hazardous use or mild dependence frequently responds to simple advice, specialty addiction treatment is usually indicated for moderate to severe dependence. The purpose of this article is to address the management of the most extreme level of addiction, heretofore not well-delineated or tested in psychiatric settings.
Although most psychiatrists understand the chronic nature of severe addiction, they may find it difficult to view it in the same light as other psychiatric illnesses such as depression, anxiety disorders or psychosis. This is primarily due to the volitional nature of initial intoxicant use and moral judgments against drug users. Substance users are likely to be seen as immoral and irresponsible people who brought their problems on themselves and, therefore, are less worthy of our sympathy or support. The association between antisocial and borderline personality disorders and addictive disorders reinforces this idea. The political demonization of illicit drug users also promotes punitive, rather than therapeutic measures. New evidence, however, demonstrates long-standing changes in brain function and structure that make drug use compulsive and extremely difficult to control or stop (Leshner, 1997). Studies have also demonstrated that both compliance and outcome in drug dependence are at least as good as, if not better than, those in other serious psychiatric disorders (O'Brien and McClellan, 1996, as cited in Willenbring, 1999). Moreover, it is pragmatically helpful for psychiatrists to adopt a chronic illness approach to addiction, not only because it helps us put aside moral judgments, but because we can apply the same skills we use to treat other illnesses to the treatment of substance dependence.
Approaching drug addiction as a true chronic illness requires a different view of goals and outcomes as well. Long-term abstinence from drug use is, of course, the optimal goal. It is a cure with permanent remission from the symptoms of drug dependence. Historically, any goal short of permanent abstinence was considered a failure. Cure is not always possible, however, and it is not the only outcome that may represent improvement or response to treatment. Temporary cessation or reduction of use, reduction in symptoms of addiction, or reduction in severity of co-existing problems are all improvements short of cure that are nevertheless worthy of pursuit. To accept a goal short of permanent abstinence is pragmatic, not "enabling," because it is realistic and appropriate, considering the natural history of the disorder. Approaching addiction realistically allows psychiatrists to do what we can (which is often quite a bit), while accepting that our treatments are only partially effective.
In the debate about national and international drug policy, harm reduction is an approach that follows something of a middle path between harshly punitive prohibition and laissez-faire legalization (Reuter and Caulkins, 1995). Many Western European nations, such as the Netherlands, Switzerland and Spain, have officially adopted harm reduction policies. Harm reduction is also commonly referred to as the public health model because of its focus on treatment and overall social and health policy, rather than on punishment (Drucker, 1995). This term is now being applied to clinical practice and refers to an approach that seeks to minimize harm and improve health and well-being, without taking an absolutist stance regarding an abstinence requirement. It functions also to distinguish long-term management of a chronic illness from conventional intensive substance abuse rehabilitation.
In other words, harm reduction is palliative care as applied to drug addiction. Because of the intensity of the national debate, however, harm reduction is a term that is loaded with symbolic meanings. To those unhappy with current policy, harm reduction is either prohibition in disguise or a sign of progress. To defenders of current policy, harm reduction is seen as a first step toward legalization.
In current practice, methadone maintenance is the best-known harm reduction approach. Maintenance treatment with a long-acting opioid such as methadone, LAAM (levo- -acetyl-methadol) or buprenorphine (Buprenex) is by far the most effective treatment for opioid addiction (National Institutes of Health, 1997). Although ongoing use of medication is generally required, it leads to substantial reductions in illicit drug use, associated crime and health and social problems. Currently, opioid maintenance can only be prescribed through a licensed program, but office prescription of methadone under the auspices of a licensed program by psychiatrists and other physicians is likely to be approved in the future. When combined with naloxone (Narcan), sublingual buprenorphine is as effective as methadone, but has much less abuse or diversion potential. When it is approved for this indication, it also will be available. These developments are likely to result in increased access to treatment for a substantial number of addicts not now receiving it.
The best-known integrated treatment for co-occurring mental and addictive disorders is based upon assertive community treatment (RachBeisel et al., 1999). This is a harm reduction model that stresses pragmatic flexible methods, long-term supportive management and gradual progress toward goals. Relapses and exacerbations are expected to occur, but proponents of this model are hopeful that they can be reduced. However, this type of program is only appropriate for patients with severe and persistent mental illnesses. Furthermore, it is not widely available, and a high degree of fidelity to the program model is necessary to achieve good outcomes (McHugo et al., 1999).
Consequently, psychiatrists treat many patients with active psychiatric and co-existing substance use disorders, and it has not been very clear how best to manage them. To assist in this area, new clinical practice guidelines for the management of substance use disorders are being developed by the U.S. Department of Veterans Affairs, which has outlined a systematic approach. In the guideline, the approach is called care management, a term more descriptive than harm reduction.
Care management (Table 2) is a harm reduction approach to addictive disorders that can be applied in a variety of settings, including psychiatric care. Like other palliative approaches, it emphasizes pragmatism, compassionate care and gradual progress toward goals (which may be less than ideal, especially initially). Care management is not the same as case management, where the focus is on coordination of care. Care management will often include some case management, and some models heavily depend on it.
Evidence for the effectiveness of care management is greater in primary care settings than psychiatric settings (where it has not been tested as much, except for assertive community treatment) (Willenbring et al., 1995;Willenbring and Olson, 1999), although care management is a common sense approach that has virtually no risk and is not time-consuming. Greater comfort and more effective communication between physician and patient are likely to improve trust, motivation, treatment compliance and, therefore, outcome. Care management will allow a fuller integration of addiction treatment techniques into psychiatric care. How much outcome is improved, or what specific outcomes are most affected, are questions requiring additional research.
Summary
The frustration many psychiatrists feel when treating substance dependent patients can be reduced by recognizing the biological basis for the disorder and its chronic relapsing course. This leads to a broader conception of goals and the adoption of long-term management techniques similar to those for other chronic and incurable disorders. The term harm reduction has been used when this palliative care approach is applied to substance use disorders. Care management, as defined in the VA Clinical Practice Guideline for the Management of Substance Use Disorders, is proposed as a more accurate and less politicized alternative. Care management is a low-risk, efficient approach that at least improves the doctor-patient relationship and may lead to improved outcomes as well.
Dr. Willenbring is director of the addictive disorders section at the Minneapolis Veterans Affairs Medical Center.
Acknowledgement
Dr. Willenbring's work was supported by the Quality Enhancement Research Initiative of VA Health Services Research and Development.
References
Drucker E (1995), Harm Reduction: a Public Health Strategy. Current Issues in Public Health 1:64-70. Available at: www.lindesmith.org/library/tlcdruck.html. Accessed Jan. 4, 2000.
Leshner AT (1997), Drug abuse and addiction treatment research: the next generation. Arch Gen Psychiatry 54(8):691-694.
McHugo GT, Drake RE, Teague GB, Xie H (1999), Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatr Serv 50(6):818-824.
National Institutes of Health (1997), Effective medical treatment of opiate addiction. NIH Consensus Statement 15(6):1-38. Available at: odp.od.nih.gov/consensus/cons/108/108_statement. htm. Accessed Jan. 4, 2000.
O'Brien CP, McClellan AT (1996), Myths about the treatment of addiction. Lancet 347(8996):_237-240.
RachBeisel J, Scott J, Dixon L (1999), Co-occurring severe mental illness and substance use disorders: a review of recent research. Psychiatr Serv 50(11):1427-1434.
Reuter P, Caulkins JP (1995), Redefining the goals of national drug policy: recommendations from a working group. Am J Public Health 85(8 Pt 1):1059-1063 [see comments].
Willenbring ML (1999), A harm reduction approach to treating substance abuse in a medical setting. Medicine & Behavior 2(2):31-32.
Willenbring ML, Olson DH (1999), A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med 159(16):1946-1952.
Willenbring ML, Olson DH, Belinski J (1995), Integrated outpatient treatment for medically ill alcoholic men: results from a quasi-experimental study. J Stud Alcohol 56(3):337-343.
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