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clinmed/2000110003v1 (November 14, 2000)
Contact author(s) for copyright information

Dr Karl Schmidt

MD, FRCPsych.,FR(ANZ)CP
MRSC, DPM, MRCS, LRCP
Medical Referee to the Home Office (Casework only)

Consultant Psychiatrist
3 Apple Close
DOWLISH WAKE
Nr. Ilminster
Somerset TA19 0QG

 

Drugs: Are we missing something?

One should not write any account, especially one that takes a somewhat critical stance on some practical aspect of a problem, unless one has an answer for it, either proven or potential.  My teams and I believe that we have one to offer relating to addictions.

There may be some agreement - although not generally acknowledged - that, if one wants to cure addicts, the following four aspects of the human personality have to be accessed:  

a) the neuro-biological, b) the psychological, c) the social, d) the existential, spiritual or religious.

If that were so and curing addicts were the goal of therapeutic interventions then the Elements of treatment programmes would obviously have to be such as to address the above four aspects.  But it is difficult to find an enumeration of such elements.  In the therapeutic programme which we have developed and practised in the80s at Yeovil District Hospital and in Brunei, there are 12 such elements.  1) the contract, 2) electro-stimulation, 3) the buddy-system, 4) prescribed readings, 5) physical relaxation exercises, 6) mental relaxation exercises, 7) in-between relaxation exercises, 8) counselling, 9) existential counselling, 10) occupational therapy, 11) family therapy, 12) anti-ictal medication

The neuro-biological aspect is probably that which has been the most neglected in any of the publications known to me including the recent ones.  There is though a vague mentioning in the Task Force report of 1996, but no details are given. 

No link is made between the considerable bodies of hard neuro-biological research available on electro-stimulation in relation to the Drug Withdrawal Syndrome.  If one wants to cure addicts, a goal mostly not stated in descriptions of therapeutic interventions, a restitution of the production and release of the endogenous opioids by non-pharmacological means would appear a pre-condition.  Let us assume that epidemiological change, either Prevalence or Incidence reduction is the goal of therapeutic interventions.  From studying the 1999 Guidelines it might appear that it is not the goal, but merely "harm reduction".  Even NTORS does not ask such awkward questions as how many addicts were cured within the period of observation, how many have relapsed in one year, and how many have been re-inserted into the work-process and into tax-paying.  Such, in my opinion essential questions, appear almost forbidden!  Nor does Dr Seivewright in his beautifully written book ask such questions.  His book is an excellent account if you believe in the epidemiological effectiveness of methadone programmes about which, obviously, I have some reservations.

They are

i. Once methadone is started, the production and release of endogenous opioids is strangled by a negative feedback-loop, since the receptors are occupied.  It could be argued therefore, that methadone programmes are anti- therapeutic (as our patients have told us).

ii. Methadone also gives the wrong idea of "a drug for drug".  

iii. Methadone so often occupies centre-stage in drug units, "detox", rehab or otherwise.

iv. Methadone programmes sometimes leave accessing the other three aspects of  the human personality as side issues, poorly dealt with.  But, they must be addressed profoundly if cure from addiction is the goal of treatment approaches.

v. Methadone programmes have proven a failure epidemiologically as regards substantially lowering the prevalence of addictive behaviours in any given community.

vi. They totally disregard the substantial body of hard neuro-biological research over the last 25 years from around the world as regards the production and   release of the endogenous opioids by non-pharmacological means.  However, various forms of electro-stimulation cause their production and release.  If they are released, the feel-good factor re-emerges in addicts, an essential  precondition for successful addiction treatment.  

vii. Some methadone programmes I know of do not teach what I like to call  "self-help instruments".  By that are meant  techniques which, if they are taught and    practised three times daily during an intensive therapeutic programme  become daily habits(as they are with the writer).  They have been found     invaluable for relapse-prevention, something to take home, as it were.

In our programme they are  a) a set of 10 physical relaxation exercises, yoga-like, b) a twenty-minute mental relaxation exercise, meditation-like and c) 12 in- between relaxation exercises, acupressure-like, elements 5, 6, 7 in the third paragraph at the beginning of this account

viii. Methadone programmes usually lack the intensive follow-up which we believe should with advantage be practised three times weekly after work(usually in groups) for two years as found essential for relapse prevention.  These appointments can in cases be 'farmed out' to GPs, AA, NA, family therapy groups or religious associations.

ix. Methadone programmes have not and cannot have any influence on Incidence  reduction on epidemiological, neuro-biological and methodological grounds.

             

A last word about electro-stimulation and the neuro-biological research underpinning it in our context.  There are 27 research papers on the subject which  Dr H L Wen, the neuro-surgeon from Hong Kong, kindly let me have including that from the department of endocrinology of St Bartholomew's Hospital, a series of papers by Prof H Ashton from the University of Newcastle, another series by Dr M Johnson from Leeds University, the book by Prof Candace Pert from USA ("Molecules of Emotions"), the recent book by Deirdre Walsh from the University of Ulster ("TENS:  clinical applications and related theory") and of course the older book of 1981 edited by HM Emrich of the Max-Planck Institute in Munich ("The Role of Endorphins in Neuro-Psychiatry", publ: Karger) and others.

We are putting this onto the web in order to structure a discussion, especially a critique as to where the authors’ thinking goes wrong.

At a later date an essay detailing a curative addiction treatment programme will be appearing on this sight, detailing approaches to all the aspects of the human personality.

 





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Right arrow Articles by Schmidt, K.
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Right arrow Articles by Schmidt, K.


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