Learning the language of abstinence in addiction treatment: some similarities between relapse-prevention with disulfiram, naltrexone, and other pharmacological antagonists and intensive "immersion" methods of foreign language teaching

Relapse-prevention (RP) is an educational process. Learning to abstain from alcohol or opiates after years of dependence involves selectively suppressing old, maladaptive habits of thought and behavior and establishing new, adaptive ones. This process resembles foreign language (FL) learning. Effective FL teaching techniques are relevant to RP. "Immersion," the most effective FL teaching method, discourages students from using their first language ab initio, requiring them to use the FL instead, however inexpertly. It resembles exposure and response-prevention for phobic or compulsive disorders. Supervised disulfiram aids RP by discouraging alcoholics from responding to real-life drinking cues in the "language" of excessive drinking, requiring them, ab initio, to practice new, alcohol-free responses. Supervised or depot naltrexone acts similarly in opiate dependence. We discuss the concept of antagonist-assisted abstinence.

Drug testing in addicts: a comparison between urine, sweat, and hair

The standard in drug testing is the immunoassay screen, followed by a gas chromatography/mass spectrometry confirmation conducted on a urine sample. Recently sweat and hair analyses were proposed for identifying drug abusers. Specimens can be collected under close supervision without embarrassment and are not subject to evasive maneuvers. In contrast with urine, hair analysis has a wide window of detection, ranging from months to years, and provides information concerning the severity and pattern of an individual's drug abuse. Testing individuals for illicit drugs with sweat patches worn continually would provide effective coverage for a week. Studies conducted in a detoxification center have shown that hair analysis is more sensitive for detecting illicit drug use than is urine screening. My experience in drug testing is discussed in the light of the existing literature.

Hair analysis as a tool for monitoring and managing patients on methadone maintenance. A discussion

Hair analysis for unprescribed drugs is not merely an effective, dignified, and time-saving alternative to urine testing. It is also more sensitive and more difficult to evade and minimises the risk of infection to clinic staff. Because of these characteristics, it can, when properly used, change the nature of the relationship between treatment personnel and patients on methadone maintenance. These changes can be beneficial and acceptable to both parties. In 263 patients, 41% of hair samples were negative for opiates, 22% had levels below 10 ng/10 mg, while in a further 7% the level was less than 20 ng/10 mg. The existing and potential advantages of this technique in managing both opiate abuse and other sorts of drug abuse are discussed.

Trivializing dependence

There are a number of repetitive behaviors which have in common what appears to be a decrease in an individual's capacity to choose to discontinue them. The taxonomy we select to categorize these behaviors depends on our objectives. Broad definition which label as 'addictions' both repetitive use of drugs and repetitive behaviors not related to drug use call attention to the loss of flexibility that the behaviors have in common. However, such broad definitions may overemphasize the value of general behavioral approaches to change and obscure the fact that seemingly similar behaviors can be dramatically changed by very different specific interventions; (for example, nicotine gum for cigarette smoking, clomipramine for obsessive compulsive disorder.) It is also possible that calling both compulsive hair-pulling and daily heroin use 'addictive disorders' may trivialize the concept of addiction and lead to an erosion of public support for research and intervention in the chemical addictions.

Combining pharmacological antagonists and behavioural psychotherapy in treating addictions. Why it is effective but unpopular

Supervised administration of disulfiram is one of the very few treatments that can significantly reduce alcohol consumption, yet it is rarely used, despite being simple and cheap. Disulfiram is not 'aversion therapy', but a technique for facilitating exposure and response prevention, and it fits comfortably into a behavioural, social-learning model of addiction (or dependence) and its treatment. The availability of other effective antagonists, notably to opiates, suggests that an approach that is demonstrably effective in alcohol dependence may be helpful in treating other addictions. The reasons for the unpopularity of this approach appear to be largely ideological.