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PD Dr. N. Scherbaum,
Klinik für Psychiatrie und Psychotherapie,
Rheinische Kliniken Essen, Universität Essen,
Virchowstrasse 174, D 45147 Essen (Germany)
Scherbaum 24
Methodology
Kuntze MF, Müller-Spahn F, Ladewig D, Bullinger AH (eds): Basic and Clinical Science of
Opioid Addiction. Bibl Psychiatr. Basel, Karger, 2003, No 170, pp 25 32
Opioid Maintenance Treatment:
The Development of Therapeutic
Strategies
Dieter Ladewig
Psychiatrische Universitätsklinik Basel, Switzerland
General Goals
Each treatment has to be adapted to the latest findings. New methods are
superior to previously practiced ones an opinion held by the mainstream of
those who believe in progress. This can produce a dilemma: should proven
methods be ignored in order to pit oneself against the idea of novel and
presumably better techniques? Is abstinence or maintenance the better goal of
therapy? A patient recently complained that treatment used to be conducted
according to stricter rules. After he himself had received abstinence-oriented
treatment, and subsequently received heroin-assisted treatment for several
years, he thought treatment had to be more flexible, since the health of the
people on the streets today had deteriorated. Flexibility is an important method
of achieving therapeutic goals.
It is often forgotten that we are always influenced by the spirit of our times.
In the 1950s addiction was regarded as the expression of a profound distur-
bance, specifically in the sense of a personality disorder that predisposed a
person to addiction; this view based on the neurosis model could also be valid
for other disorders. In addition the addict was seen within a moralizing context
featuring attributes such as flaws of character, prevarication and antagonism.
The illegality of drug use and the numerous concomitant forms of delinquency
resulted in the logical conclusion that it was necessary to punish the drug
delinquent. The large penal institutions for narcotic addicts in the USA, where
convicted opiate users were incarcerated and treated from the 1930s to the
1960s corresponded to a strategy that sanctioned abnormal behavior and
attempted to correct it by training and reformation.
At the end of the 1960s, this strategy was fundamentally altered by two
diametrically opposed schools of thought: namely, the idea and putting into
practice of a therapeutic community (Synenon), and the hypothesis that opiate
use could be grounded in a biological deficit that might be relieved by an
opioid. This resulted in two different strategies, one social-psychologically
oriented and the other biologically oriented. Common to both was the view that
deficits were the cause of the disorder, on the one hand socialization deficits,
on the other biologically grounded deficiency syndromes. Both views also held
that incarceration, however long, could not facilitate full improvement. The lat-
ter was particularly emphasized when Abraham Wikler in Lexington, Ky. deter-
mined that conditioned withdrawal syndromes were elicited when former opiate
addicts left the sheltered settings of the institutions and returned to their home
town environments resulting in renewed consumption. It was, therefore,
concluded that learning to live with disruptions in the community whether
supported by a therapeutic group or by using methadone could facilitate an
improved lifestyle.
For me, the question of abstinence or maintenance is less important than
the necessity of adopting a basic position and of diagnosing and treating
substance-related disorders. This should allow the person concerned to have a
certain degree of emotional well-being in the sense of ameliorating his or her
complaints in order to learn to cope effectively with the problems of life and,
further, to control threatening emotions such as shame, guilt, pain or despair.
As a result the patient can eventually be shown realistic ways of living a life of
abstinence. This knowledge will permit him to experience respect and trust in
himself and others.
The 4-Pillar Model
When this basic position becomes a feature of public debate, a basis for
drug policy will be established, which is neither exclusively repressive nor
exclusively permissive. In many Swiss cities drug commissions were set up in
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