29th March 2005
Dr Stephen Jurd, Ms Josette Freeman, Dr Alex Wodak, Ms Lyn Roberts.
This session focussed on non-pharmacological management approaches to substance abuse. Stephen Jurd, director of D&A services at RNSH began the session by giving an overview of Alcoholics Anonymous ('AA'). He first presented us with the evidence for a genetic proclivity to alcohol dependence. He defined the dependence syndrome with reference to alcohol. This syndrome includes narrowing of the behavioural repertoire, salience of drinking, increased tolerance to alcohol, subjective awareness of the compulsion to drink, increased frequency and severity of withdrawal symptoms as dependence on alcohol increases and the seeking of relief from withdrawal symptoms by drinking more alcohol. There is also often a rapid return to pre-abstinence levels of drinking after a period of abstinence. He pointed out that controlled drinking for someone with an alcohol dependent syndrome would be very difficult to achieve, and that the two most likely outcomes for heavy drinkers were either a move to abstinence or eventual death from the complications of alcohol overuse.
AA, a 12-step approach, is not just about attending meetings, but a comprehensive philosophy. It does not tell people to "stop drinking" and has no opinion on any outside issues. We were told about the importance of the AA facilitators in encouraging people to attend meetings and connect with people. If people are just told the time and place of a meeting, it is not very likely that they will turn up, so the facilitators ring the prospective attendees to remind them of the upcoming AA events. This demonstrates the emphasis on personal contact that is integral to AA or the 'fellowship'.
Reference was made to the "clichés" used by AA, but Stephen Jurd asserted that if used skilfully they can change people's thinking. Some of these clichés include: "one day at a time", "live and let live", "easy does it", "let it begin with me". The literature that AA produces includes 3 major arms: 1) the AA big book 2) Living Sober, 3) the 12-steps and 12 traditions manual. The "Living Sober" book contains a lot of very practical advice to commonly asked questions such as should I avoid parties? How to I approach sex when I'm not drunk? and what do I do if I can't sleep? The AA groups require regular attendance, and there is usually a group task that is done each session to facilitate the sense of community and aid motivation. There is a group "conscience" whereby particular issues may need to be voted upon and a consensus reached. The 12-steps are the actual AA "program" and the meetings are centred around these 12 steps. Workbooks are available (eg at the Sydney 'Feminist' bookshop). A group member will often have a "sponsor" whose task it is to go through certain steps with the attendee. Sometimes it is required that these steps are written down (step 4). It is up to the attendee as to whether they want their sponsor to be temporary to cover certain steps, or long-term. A sponsor's role can include such things as ringing the person at a certain time each day to see how they are going.
There were questions about whether AA was religious, and though it did originally have Christian roots (the 'Oxford group'), it is now regarded in Australia as having no religious aims or affiliations. The term "God", as mentioned in AA literature, can be taken religiously or in any other way, eg as an acronym for "gathering of drunks" (!). It was noted by Alex Wodak that there is no hard evidence to prove that AA works, but he felt that as AA is a community organisation there should be no onus on it to have to prove its mettle. He believed it would be a difficult thing to assess scientifically, particularly for reasons of confidentiality and privacy. Stephen Jurd pointed out that there are currently about 2 million members of AA worldwide, and that it draws no outside funding yet has continued to exist for many years. He considers this to be suggestive of its merit. He said there is a bit of scant evidence for AA, but you have to scratch around for the data, and it's not "level 1" evidence. (ie double blind randomised control studies.)
Josette Freeman spoke to us about the SMART Recovery programme of which she is the co-ordinator, based at St Vincent's Hospital. They have a grant to establish 20 SMART recovery groups across NSW. SMART ("self management and recovery training") originated in the 1990's in the USA and is based on cognitive behavioural therapy (CBT) principles. The groups are peer-run. One of the principal objectives is to help foster motivation within people so that they are self-propelled towards recovery. The programme cultivates self-help and problem solving skills. People learn how to identify and manage their urges to use their drug of dependence. They work towards achieving a balanced lifestyle. The programme's CBT approach teaches people to challenge unhelpful automatic thoughts that surround their drug use. It is a time-limited commitment of a minimum of five weeks, though some people attend for up to 18 months.
In SMART, members are encouraged to do a cost/benefit analysis of their drug use. Relapses are looked at by the group and studied to see what has lead up to them. Analysing relapses is seen as part of the group's learning curve. Looking at the here and now is important, and meetings encourage people to study what has worked and not worked for them during the past week. Facilitators are encouraged to network with each other and share ideas about the running of their groups. SMART can complement adjunctive pharmacotherapies being used to treat substance misuse. It is not a substitution or competitor to the 12-step programme and members can attend both programmes if they wish. Group attendees may use different drugs of dependence, like alcohol and opiates, so in this sense the groups are "mixed". Josette described SMART as being an abstinence programme with latitude. The programme has not been evaluated, though discussions regarding this are currently happening with NDARC.
Alex Wodak commented that SMART, like AA, is a community resource and therefore shouldn't have to be evidence-based, though a positive evaluation would encourage health professionals to refer to it. Josette explained that for a client to be suitable for SMART, they must want to go. She said it offers an alternative to those people who don't like the 12-step approach, including the 'higher power' and 'disease concept', thus opening up more options for those with drug and alcohol dependency problems.
Lyn Roberts spoke to us about the therapeutic community model of treatment. She is manager of WHOS MTAR. This acronym stands for 'we help ourselves' and 'methadone to abstinence residential'. It is a residential service for those wishing to withdraw from methadone maintenance therapy. The methadone reduction regime is managed by external GPs as well as being externally dosed at the Langton Centre. There is a recommended protocol of dose reduction of methadone, but clients have the right to delay the reduction. Lyn Roberts stressed that conceptually it is important to understand that MTAR is not a "detox", but clients are undergoing their reduction while they are going through their rehabilitation program. Therapeutic community staff primarily utilise facilitation as a means of engagement as opposed to traditional medical models of treatment. Clients are referred to as residents, not patients, with the expectation that they will take responsibility for their own recovery. They are encouraged to support staff with the orientation of new clients, and the maintenance of the program schedule. They celebrate achievement of goals. MTAR came about after networking with USA TCs, but the Australian approach is modified and more flexible than a traditional American TC. Clients are not required to do as many functions as in a traditional TC and if a client prematurely discharges themselves, they are allowed back into the program within a 3 day time span if assessed as appropriate for readmission. Peer support is an integral part of the TC model and utilises privileges as part of its programme. Insight is gained through group and one-on-one interaction. Clients have access to harm minimisation programmes at MTAR eg educational sessions on hep C and HIV, drug overdose, infection control, etc. There is provision for safe injecting equipment and safe sex supplies throughout all WHOS facilities including MTAR. The recommended length of stay is 4-6 months. Lyn explained that MTAR is in the process of doing follow-up studies on its clients, but felt already that the high retention rates of clients in the programme provided some evidence of its success.