Alcohol and drug addictions are complex issues that require specialised diagnosis, treatment and aftercare. Professor Jonathan Chick MA (Cantab), MPhil, MBChB, DSc, FRCPsych, FRCPE, Medical Director at Castle Craig Hospitals, explains how residential treatment can alleviate withdrawal symptoms and allow better management of complex cases so as to facilitate an easier and speedier recovery.

Extensive research (Koob and Volkow, 2016) on brain disturbances connected to withdrawal from alcohol and drug abuse, indicates two major findings:

Negative emotional stress (shown in decreased dopamine levels in the reward system) Increase of brain stress neurotransmitters (such as corticotrophin-releasing factor and dynorphin)

It has sometimes been found possible to detoxify some patients with alcohol or drug dependencies, using psychological support and monitored dosages of substitute medications. This is done in order to alleviate the immediate physical symptoms of withdrawal as well as the emotional and mental effects. Many patients experience a 'negative' phase of depression, anxiety and low energy that occurs during the first few weeks.

However, many people find it difficult to detoxify on an outpatient basis and require a more secure and focused environment. Rehabilitation in a treatment centre provides a safe place free from drugs and alcohol, where the craving for drugs and alcohol cannot cause relapse. Such places offer these advantages:

The addictive substance such as alcohol or drugs is not available.
The patients emotional and mental state can be regularly monitored, assessed and treated by on-site staff.
Suitable medication to combat the side effects of withdrawal are available.

It has been found that daily medication and medical supervision often ceases to be necessary after a week of treatment.

However, it has been found that, if cravings persist beyond the first week, the likelihood of relapse is greater (Sinha and O'Malley 1999). In such instances, a longer stay would be recommended. Further specialised treatment in order to alleviate cravings as well as medical and psychiatric symptoms could then be given.

Another complication that can arise from withdrawal is insomnia. Sleeping patterns will remain abnormal for a number of weeks after detoxification. These sleeping issues are often used to predict the risk of relapse even when a patient's' quality of life as well as other psychiatric symptoms are improving (Brower et al., 2010) (Cohn et al., 2003). By extending treatment into the 3rd and 4th week, on-site staff are able to make a significant evaluation and restoration of a patient's sleeping pattern and ultimately aid in preventing relapse.

How Being Addicted to Multiple Substances can Complicate Recovery

Opiate-induced Hyperalgesia

Hyperalgesia is a condition where a person becomes more sensitive to the sensation of pain.
Within the last decade, patients who report chronic pain have been increasingly prescribed opiates.This can lead to opiate-induced hyperalgesia (Westergaard et al, 2016; Lee et al, 2011) and abuse or addiction to opiates. This cycle of drug usage can lead to an addiction and drug abuse. Equally, alcohol can provoke hyperalgesia when used regularly as can the excessive use of benzodiazepines (Torrance et al, 2018).

Depending on the level of drug abuse of opioids, detoxification can take 3-4 weeks, even with other pain control treatments and physiotherapy. In some cases, these symptoms may increase the chance of a patient being taken in for unnecessary and sometimes harmful surgery. However, with the help of intensive residential hospital care and specialist nurses and doctors - many of the physical symptoms of withdrawal can be successfully managed. This will normally entail the patient learning and practicing other successful pain management methods.

Multiple drug use

The rise of the dark web, as well as the ability to purchase addictive substances through the established internet has led to an increase in multiple addictions. Typical mixes could be benzodiazepines and synthetic cannabinoids (such as spice) or GHB and alcohol.

These combined substances require an even longer period of medical supervision to complete successful detoxification. This is due to the high risk of seizures as well as psychiatric symptoms such as agitation and paranoid delusions. It is very difficult to monitor these states on an out-patient basis.

Dual Diagnoses and Complex Problems

Patients suffering from addiction commonly have other psychiatric and physical issues that require treatment. Often, patients with alcohol disorders are likely to have been victims of trauma (Fetzner et al., 2010), with high comorbidity rates in depressive disorders (Kessler, 2005) as well as PTSD (Debell et al. 2014). At a symptomatic level, comorbid depressive and post-traumatic phenomena are greatly influenced by alcohol use as well as withdrawal from it (Liappas et al. 2002).

The American Society of Addiction Medicine (ASAM) has developed a taxonomy of addiction only services (AOS) as well as Dual Diagnosis Capable (DDC) and Dual Diagnosis Enhanced (DDE). Both DDC and DDE allow for the capability of integrating treatment for both disorders. (McGovern et al, 1999).

Patients with complex problems have been found to relapse more often in the first year after treatment than patients without complex issues (Simpson et al, 1999). However, accurately testing this would prove to be unethical, as it would require randomly allocating patients to a longer or shorter stay.

Yet a study following for 12 months after treatment with 804 patients of alcohol dependence, who were treated in hospitals where enhanced treatment was given, compared the results of patients with and without complex problems. They found that patients that underwent enhanced residential treatment programmes along with medical-based treatment, were not higher in relapse rates than those without complex problems. This appears to show that these enhanced programmes are effective at managing dual-diagnosis patients. (Schoenthaler et al, 2017) This study helps to answer the question whether these issues are better dealt with separately or simultaneously. (Drake et al, 2004)

The ethical issues concerning these types of studies have been alleviated by randomly allocating specific extra treatment for comorbidly ill patients in residential programmes. It was shown that those who received extra treatment for their conditions had reduced relapse rates, particularly with regard to depression and/or trauma symptoms. (Ostergaard et al, 2018)

By Professor Jonathan Chick

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