Seek a balanced approach to medications

Many substance abuse treatment programs are still struggling to identify the best role for medications in their clients' treatment plans. Arguing that medication in and of itself is good or bad is as ridiculous as arguing whether sunshine is good or bad. The right amount of sunshine brightens our world and gives us vitamin D; the wrong amount can contribute to sunburn or skin cancer. To disconnect a discussion of medication from the goal of optimal health is not sensible.

A program's health and mental health staff should be responsible for prescribing and dispensing medication within the context of principles agreed upon by the entire staff. Disagreements will arise not out of these principles, but over their application. Each staff member is bound by an ethical mandate not to practice outside the scope of his/her credential and expertise.

Addiction counselors, nurses, and social workers, for example, have a role in the medication discussion. They can help by observing clients and reporting information to the prescribing physician. They might even recommend getting a second opinion. But under no circumstances may they overrule a physician who has prescribed medication. They do not have the legal, moral, or ethical authority to do that, and doing so would establish grounds for dismissal and the filing of a formal complaint against their credential.

Positions at the extremes

Twenty years ago, a clear prejudice existed against the use of psychotherapeutic medication. At self-help meetings and addiction programs, people were told they could not consider themselves drug-free if they took medication. In some circles today, psychotropic medication might be used as the first or only treatment option.

Either of these situations is unethical and unfair to clients, since research supports neither course of action. Clients are best served when a multidisciplinary team is guided by agreed-upon principles, and each team member is valued for his/her area of expertise.

One characteristic that many researchers, doctors, and counselors have in common is a tendency to overestimate the efficacy of specific pharmacological or counseling interventions. One's style of communicating is at least as important as the specific intervention used.1 A high expectation for success also serves as a contributing factor in treatment success. It contributes to treatment compliance and, therefore, successful outcomes. A satisfactory outcome in one-third or more of all clients may be attributed to the placebo effect.

Principles to apply

Here are some principles that can guide decision making regarding medications:

• The optimal amount of medication supports healthy choices by the client. Both too much medication and not enough can undermine healthy choices. If clients were in so much pain that they couldn't think straight, medication would be indicated. If clients were turned into zombies whose senses were dulled to the point where they had no awareness of the things around them, that would constitute too much medication.

• Medication should be used to quiet unhelpful symptoms, and should enhance rather than diminish clients' abilities of self-management. Severe pain or hearing voices constitute examples of unhelpful symptoms that medication can quiet. Cognitive dissonance that clients can resolve to their benefit without medication constitutes an example of a helpful discomfort.

• Medication should be used to restore volition, and not to undermine clients' power of choice. Part of what qualifies clients for certain diagnoses is the loss of volition. Certain symptoms beyond clients' control can be addressed with medication. Medication should not be used to undermine clients' power of choice, by unnecessarily limiting their awareness or their ability to assess themselves rationally.

• For anyone who takes medication, it is important to understand what the medication can accomplish, as well as those things that remain the patient's responsibility. This is where treatment team collaboration can be effective. Most often, the counselor will address matters within the client's power of choice, and the prescribing physician will address things mostly outside the client's control. This is a partnership too important to the client to risk being undermined by any prejudgments that medicine is good or bad.

Nicholas A. Roes, PhD, has written hundreds of articles and several books, including Solutions for the ‘Treatment-Resistant’ Addicted Client (Haworth Press, 2002; reviewed in the January 2003 issue of Addiction Professional). He is Executive Director of the New Hope Manor residential treatment facility in upstate New York, a regular presenter at conferences, and a leader of staff trainings for professionals. The author would like to thank Vladimir Ginzburg, MD, Board Certified in Addiction Psychiatry, for his review of and suggestions for this article. Roes' e-mail address is NickARoes@aol.com and his Web site is https://www.nickroes.com.

Reference

1. Hubble MA, Duncan BL, Miller SD. The Heart and Soul of Change: What Works in Therapy. Washington D.C.:American Psychological Association; 1999.