1. OVERVIEW OF TREATMENT APPROACHES FOR OPIATE ADDICTION: A
SCOTTISH PERSPECTIVE
Substance use disorders are some of the most widespread mental and behavioural
disorders affecting individuals on a global scale. Substance dependence is characterised
by compulsive and uncontrollable use of a substance and is associated with physiological
withdrawal symptoms with the sole pursuit of substance use despite the occurrence of
serious harm to self or others (Abou-Saleh, 2006). Opiate derivatives such as heroin have
been recognised as some of the most addictive and problematic substances in the world
today with the total number of opiate users at a global level now estimated at
approximately 16.5 million people with the annual prevalence rate of 0.4% of the
population aged 15-64 having remained stable since the 1990’s (United Nations
Department Of Drugs and Crime 2008). Europe remains the second largest consumer
market for opiates with the United Kingdom being one of the major opiate markets in
Western Europe with and estimated number of 340,000 people consuming these drugs
(United Nations DODC, 2008). Scotland in particular has a significant number of
problem users with an estimated 52,000 people experiencing drug dependence, a number
that is notably higher than for England as well as other similar European countries such
as Ireland, Finland or Denmark (Scottish Executive 2008). Research based on the
outcomes of the Drug Outcomes Research in Scotland study (DORIS) indicates that
problem drug use in Scotland has been recognised as having a significant impact on
mortality rates in comparison to the rest of the UK (Bloor, Gannon, Hay, Jackson,
Leyland & McKaganey, 2008). The impact of problem drug use on the individual and
society as a whole is profound with injecting drug use being associated with a high risk
for contracting blood-borne infections including HIV, hepatitis C and Hepatitis B (Abou-
Saleh, 2006). Recent figures for Scotland demonstrated that 85% of Hepatitis C sufferers
contracted the disease from sharing injecting equipment and other paraphernalia (Scottish
Executive 2008). Problematic heroin use is also associated with deterioration in self-
esteem and social relationships (Wermuth, Brummett & Sorensen, 1987) and has also
been found to have enormous social costs due to crime and unemployment (Amato,
Davoli, Perucci, Ferri, Faggiano & Mattick, 2005; Scottish Executive, 2008). It is clear
that problematic drug use, and in particular addiction to opiate derivatives such as heroin
has had a significant impact over the past 20 years and as a result a great deal of research
has been carried out as to the most effective methods of treatment and care for
individuals affected by this issue.
The most widely available treatment intervention for opiate dependence is the use of
pharmacotherapy which aims to alleviate craving and withdrawal symptoms associated
with illicit opiates, or facilitate detoxification from illicit opiates. This is achieved by
administering stable or tapered doses of medications to the heroin user. This can be
achieved by substituting illicit opiates for clinician prescribed opiate-based medications.
The two most widely prescribed medications for this are methadone and buprenorphine
(Lingford-Hughes, Welch & Nut, 2004). The primary aim of such interventions is to
allow opiate dependent individuals to regain a greater degree of control over their heroin
use which in turn will lead to a reduction in time spent on drug related activities with the

2. future aim of entering into detoxification, and eventually achieving an opiate free life
(Ward, Hall & Mattick, 1997). In the United Kingdom, the standard substitute drug of
choice is methadone (Matheson, Bond, & Hickey, 1999; Wilson, Watson & Ralston,
1994; Best, Gossop, Marsden, Farrell & Strang, 1997). Recent figures for Scotland
indicated that the number of prescriptions for methadone mixture was estimated at
457,092 and that methadone prescribing rates have risen by 45% over the last five years,
from 62 per 1,000 population in 2001/02 to 90 per 1,000 population in 2005/06
(statistical publication notice, Information Services Division NHS 2006).
Methadone substitute treatments have consistently provided evidence demonstrating a
sustained reduction in illicit drug use among heroin users (Dole et al., 1969; Gunne &
Gronbladh, 1981; Newman & Whitehill, 1979; Simpson, Joe, Dansereau, & Chatham,
1997; Ward et al 1997; Yancovitz et al., 1991). Methadone-based treatment programmes
have also demonstrated increases in the time between frequency, intensity and length of
heroin use relapse (Leshner, 1998), as well as reductions in overdose risk, criminal
activity and exposure to blood-borne viruses (Farrell et al., 1994; Leshner, 1998; Ward et
al., 1999). Detoxification from opiates can also be achieved using tapered doses of
methadone or buprenorphine, or using α-adrenergic medications such as clonidine or
lofexadine to suppress withdrawal symptoms (Lingford-Hughes et al., 2004).
However, despite its effectiveness in reducing dependency on illicit opiates such as
heroin, methadone substitution therapies have not been without criticism. The initial
stages following the introduction of methadone maintenance programmes in Glasgow in
1994 resulted in a substantial increase in drug-related deaths as a result of a lack of
consistency and regulation of prescriptions and dispensing (Seymour, Black, Jay, Cooper,
Weir & Oliver, 2003). An early review of methadone based substitution treatments
highlighted a number of problematic factors associated with methadone including, the
addictive nature of methadone itself and the need for gradual detoxification to effectively
achieve opiate-free status (White, 1994). This review also indicated that methadone can
also increase the toxicity of other drugs including benzodiazapines and alcohol due to its
depressive effect on the central nervous system (White, 1994). Recent research carried
out by the Scottish Drugs Forum as part of the Scottish Executive’s review of methadone
based treatment interventions highlighted that although such treatments were effective in
achieving a degree of stability in the lives of service users, it was highlighted that many
service users and their carers viewed methadone as simply replacing one drug with
another and that such treatment programmes were aimed at crime reduction rather than
facilitating positive long-lasting change for the service user (Scottish Drugs Forum 2006).
Other difficulties highlighted included the lack of consistency in service delivery and
provision as well as a lack of service user involvement in care planning and a distinct
lack of support with regards to the underlying psychological and social factors associated
with their drug use (SDF, 2006). Further research has also indicated that the stigma
associated with drug treatment services themselves can be a significant reason for
disengagement (Copeland, 1997). Radcliffe & Stevens (2008) highlighted that for some
heroin users, the treatment regime itself could be stigmatising due to segregation in
pharmacies and supervised consumption. It was also evident that methadone maintenance
prescriptions marked out recipients as separate from and outside ‘normal’ life

3. encompassing difficulties with maintaining employment and for travel within and outside
the UK (Radcliffe & Stevens, 2008). Early research has also highlighted the vulnerability
of individuals moving towards a gradual decrease in methadone substitution treatment
due to a lack of adequate support and structured aftercare to ensure abstinence and
prevent relapse (Wermuth, Brummet & Sorensen, 1987).
As well as pharmacological interventions, the self-help movement has led to a vast
increase in 12-step programmes aimed at promoting recovery and maintaining abstinence
from addictive substances (Peteet, 1993; Fenster, 2006; Vederhus & Kristensen, 2006).
The popularity of such approaches began with the establishment of Alcoholics
Anonymous in 1935 (AA, 2008) with Narcotics Anonymous appearing 20 years later
(NA, 2008). The philosophies of groups such as NA are based on a group of principles
that are intended to be practiced as a way of life (NA, 2008). These include the admission
of a problem; the searching for help; thorough self examination; practicing amends for
harms done to others; and ultimately helping other drug addicts to recover and achieve a
promised ‘spiritual awakening’ (NA, 2008). The focus of this approach is the disease
model of addiction whereby substance dependent individuals are thought to suffer from a
chronic disease that is out with their control and that recovery can only be achieved
through lifelong abstinence (NA, 2008; King, Bissell & O’Brien, 1979, Peteet, 1993).
Limited research in this field has highlighted the apparent efficacy of 12-step
programmes as a treatment approach in the reduction of drug use and maintained
abstinence (Connors, Tonigan & Miller, 2001; Moos & Moos, 2004; Hoffmann, Harrison
& Belille, 1983). Twelve-step programmes have also demonstrated positive change by
enabling service users to establish new social networks (Kaskutas, Bond & Humphreys,
2002), and to achieve increased self-esteem and a subjective improvement in social status
(Zemore, Kaskutas & Ammon, 2004). Research by Peteet (1993) also suggested that 12-
step programmes provide accessible group support and address individuals’ needs for
identity, integrity and interdependence within a larger social, moral or spiritual context.
The potential cost-effectiveness of such programmes has also been highlighted although
further research in this area is necessary to determine the overall benefits (Kelly,2003).
However, despite the growing body of research concerning the positive benefits of 12-
step programmes and their considerable distribution in the United States, the situation in
the UK is very different with most National Health Service (NHS) statutory services
demonstrating considerably less utilisation of 12-step ideology (Day, Gaston, Furlong,
Murali & Copello, 2005). This has been attributed to a degree of cynicism towards such
programmes within both substance using and professional cultures (Wells, 2005). A
review of the research regarding the effectiveness of 12-step programmes indicated that
although there was a growing body of empirical evidence for the efficacy of AA as a
treatment approach for those with alcohol dependence, little is known about the specific
effectiveness of other self-help groups focused primarily on other substances such as NA
(Kelly, 2003). High drop-out rates have also been demonstrated with regards to 12-step
programmes with some research demonstrating up to 50% drop-out rates within the 90-
day introductory period (Humphreys, Huebsch, Finney & Moos, 1999; McIntire, 2000).
Earlier research by Peteet (1993) highlighted some of the criticisms that have been
associated with 12-step programmes including their inability to address and facilitate
understanding of the dynamic roots of addictive behaviour as well as their focus on

4. interdependence rather than independence, and encouragement of powerlessness and a
lack of responsibility for one’s behaviour and recovery. Another continuing issue with
regards to 12-step programmes is their strong religious overtones, which may serve as a
barrier to service user utilisation (Peteet, 1993). Other barriers that have been noted with
regards to 12-step programmes include some members’ negative view towards
individuals taking psychotropic medication in conjunction with their affiliation with these
groups (Kelly, 2003; Rychtarick, Connors, Dermen & Stasiewicz, 2000). It has also been
suggested that opiate dependent patients who are using methadone treatment view the 12-
step principle of total abstinence from all narcotic use as a significant barrier to accessing
programmes such as NA (Kelly, 2003).
The field of psychological research has seen the development of a number of theories
with regards to addictive behaviour which has served to generate several treatment
approaches to address this issue (Wanigaratne, 2006). Social Learning Theory as first
introduced by Bandura (1977) served to introduce the concept of cognitive processes in
learning. Cognitive factors such as anticipation, planning, attributions, self-efficacy and
decision making were all shown to be significant in learning (Wanigaratne, 2006).
Marlatt & Gordon (1985) proposed the cognitive-behavioural model of the relapse
process and the subsequent treatment approach that has been developed as a result of this
has had a significant impact in the treatment field (Wanigaratne, 2006). Interventions
based on this model contain elements which serve to increase the service user’s
awareness of the relapse process in general as well as their own individual pattern in
relation to this (Wanigaratne, 2006). Such approaches examine the patterns of
individuals’ previous relapse experiences and increase insight by identifying individual
strengths and weaknesses and involve skills training to work towards establishing
positive coping strategies (Wanigaratne, 2006). Relapse prevention strategies have
demonstrated promising treatment outcomes in the field of substance misuse (Rawson,
Obert, McCann & Marinelli-Casey, 1993). Research examining the efficacy of an
intensive outpatient treatment model for opioid users which incorporated relapse
prevention principles in combination with self-help concepts indicated positive treatment
outcomes (McAuliffe, 1990; McAuliffe & Ch’ien, 1986). Positive outcomes included
superior levels of opioid abstinence at 6 and 12 months follow-up as well as significantly
more employment activity and less criminal activity in comparison to the control group
(McAuliffe, 1990). Other relapse prevention programmes such as Self Management and
Recovery Training (SMART) have combined priniciples of Rational Emotive Behaviour
Therapy (Ellis, 1988) and cognitive techniques to secure abstinence and promote self
awareness and positive coping techniques (Fenster, 2006). Although some research
examining the treatment outcomes of programmes such as SMART have demonstrated
significant results (Brooks & Penn, 2003), there is still a significant lack of empirical
research examining the efficacy of such treatments (Kelly, 2003).
Other psychological theories that have emerged with regards to addiction include
Psychodynamic approaches which suggest that substance dependence is closely linked
with pre-existing underlying psychopathology and an inability to cope with resulting
painful emotions (Wurmser, 1973) as well as being strongly associated with past
traumatic experiences (Hopper, 1995). Khantzian (1977) introduced the concept of self-
medication as a motivation for substance misuse. This in turn has had considerable

5. influence in the field of comorbid substance misuse and mental illness (Wanigaratne,
2006). Treatment approaches based on these principles have involved helping the
individual to achieve abstinence through the therapeutic relationship with a drugs worker
(Wanigaratne, 2006). However, although counselling based on psychodynamic
principles became the main intervention in various treatment settings, it was often
carried out by individuals with little or no knowledge of underlying psychodynamic
processes (Wanigaratne, 2006). It is suggested that this lack of clear framework in
treatment settings is related to limited treatment outcomes using this approach
(Wanigaratne, 2006).
One of the most influential psychological models in the field of addiction has been the
Stages of Change model originally developed by Prochaska & DiClemente (1996). The
central concept of the model is motivation and its considerable role in explaining why
and how people change addictive and health behaviours (DiClemente, Nidecker &
Bellack, 2006). The model suggests that behaviour change takes place in discreet stages:
the pre-contemplation stage; the contemplation stage; the decision stage; and the
maintenance stage in which successful change in behaviour is achieved (Prochaska &
DiClemente, 1996). A key treatment approach that has been developed as a result of this
model is Motivational Interviewing (Miller & Rollnick, 1986). Motivational
interviewing can be thought of as a client-centred counselling style incorporating non-
judgemental, empathetic and non-confrontational principles to facilitate a supportive
environment in which clients can explore both positive and negative aspects of their
behaviour (Miller & Rollnick, 1991). The main aim of Motivation Interviewing is to
assist service users to work through their ambivalence about behaviour change and it has
been found to be effective for those who are in the beginning stages of readiness for
change (Miller & Rollnick, 1991; Resnicow, Dilorio, Soet, Borrelli, Hecht & Ernst,
2002). Motivational enhancement techniques have been found to produce improved
outcomes in a range of substance misuse patients (Miller & Rollnick, 2002; Stotts,
Schmitz, Rhoades & Grabowski, 2001). Such approaches have also been shown to
improve treatment engagement and retention in individuals with comorbid substance
misuse and mental health issues (Swanson, Pantalon & Cohen, 1999; Daley, Salloum,
Zuckoff, Kirisee & Thase, 1998).
Psychosocial interventions are continuing to gain greater status in treatment approaches
to addiction and the growing body of evidence based practice has highlighted that future
directions should involve the integration of different psychological approaches in order to
make available a range of targeted treatments to substance dependent individuals at
different stages of the recovery process (Wanigaratne, 2006; Wanigaratne & Keaney,
2002) which in turn could serve to enhance positive treatment outcomes, particularly for
those with comorbid substance use and psychiatric disorders (DiClemente et al. 2006;
Mueser, Noordsy, Drake & Fox, 2003). Clinicians and service providers have long been
aware that service users with substance use issues frequently presented with psychiatric
conditions in conjunction with, preceding or following on from the substance use
disorder itself (Glass & Jackson, 1988). The World Health Organisation (WHO) and the
United Nations Office on Drugs and Crime (UNODC) define dual diagnosis as “a person
diagnosed as having an alcohol or drug abuse problem in addition to some other

6. diagnosis, usually psychiatric such as mood disorder or schizophrenia”, while the
European Monitoring Centre in Drug Dependence and Alcohol (2004) make reference to
co-morbidity or dual diagnosis as being the co-existence of two or more psychiatric or
personality disorders as defined by the International Classification Diagnostic System
(WHO, ICD-10 1993).
The relationship that exists in co-morbidity is complex and can present in many different
ways (Crome, 1999). Symptoms of psychiatric or psychological disorders may result
from substance use, dependence, intoxication or withdrawal. Moreover, psychiatric
disorders may lead to or precipitate substance misuse, which in turn can lead to
psychiatric syndromes (Baldacchino, A., 2007).
Various early studies have demonstrated the prevalence of co-occurring mental disorders
and substance use disorders (Robins & Regier, 1991). The 1990 Epidemiological
Catchment Area (ECA) study in the United States was one of the first population surveys
conducted that demonstrated 29% of people presenting with a mental disorder had also
experienced a substance use disorder. Conversely, they found that 64% of people being
treated for drug disorders had at least one co-morbid mental illness (Regier, Farmer, Rae
et al., 1990). Further research carried out by the National Co-morbidity Study (NCS) in
1994 found that 48% of people surveyed reported a substance misuse disorder or
psychiatric illness in their lifetime (Kessler, McGonagle, Khaao, et al.1994). Studies
involving individuals whose primary disorder was substance use indicated that the most
prevalent co-morbid mental disorders were anxiety disorders, affective disorders,
antisocial personality disorders and schizophrenia (Regier et al., 1990). Borderline
personality disorder is also strongly associated with problematic drug use (American
Psychiatric Association 2000; Trull, Sher, Minks-Brown, Durbin & Burr, R., 2000).
A report released by the Scottish Executive in 2003 (Mind the Gaps: Meeting the Needs
of People with Co-occurring Substance Misuse and Mental Health Problems ) is
described as compendium of evidence-based Scottish research highlighting the
prevalence and treatment recommendations for those with co-morbid substance use and
mental health issues (Scottish Advisory Committee on Alcohol/Drug Misuse 2002). The
evidence compiled highlighted that 3 out of 4 drug using clients engaging with services
were reported as having mental health problems, and that an estimated 2 in 5 people
presenting primarily with mental health problems also had a drug and/or alcohol problem,
( Scottish Executive 2003). Evidence from the Scottish drug Misuse Database (SDMD)
showed that for the period of April 2001 to March 2002 over 40% of people who sought
treatment reported that their mental health was one of the main issues which led them to
seek treatment (Scottish Executive 2003). Further research gathered for the report also
indicated that in a nationally representative sample of Scottish general medical practices
35.2% of consultations with drug misusing patients were for either mood or anxiety
related disorders (Scottish Executive 2003).
The presence of co-morbid psychiatric conditions and the severity of psychosocial
problems have been related to poorer treatment outcomes across a variety of studies
(McNulty, J., Kouimtsidis, C., 2001). Research has highlighted difficulties with non-

7. adherence with medications, symptom exacerbation, re-hospitalisation, poor social
adjustment, an overall lack of therapeutic engagement and relapse after initial successful
change in dually diagnosed individuals ( Blanchard, 2000; McGovern, Wrisley, & Drake,
2005; Mueser, Drake, Turner, & McGovern, 2006).
There are a wide range of pharmacological treatments used for the purposes of attracting,
engaging and retaining service users, and to enhance motivation to seek further support
from specific psychological treatments in relapse prevention (Baldacchinno, 2007)
Furthermore, there are increasing numbers of guidelines being established for the
treatment of substance misuse and/or mental illness (Hole, 2005; Ludbrook, Bird & van
Teijlingen, 2005; Department of Health - Drug Misuse and Dependence, 1999; Effective
Interventions Unit, 2002). However, research carried out by Mental Health Foundation,
supported by Turning Point Scotland, in 2003 found that the views of many service users
highlighted significant problems in service provision. Views expressed by service users
included feeling that services only focused on one problem rather than the range of
problems they faced, and the fact that many felt that had been prevented from accessing
mental health services until their substance misuse issues had been addressed first. The
view that accessibility was difficult due to long waiting lists and inflexible appointment
times being offered were also expressed (MHF, 2003). Other research in this area has
also indicated that there is a tendency for services to separate general psychiatric and
substance misuse issues. The result is that some people can fall through the cracks
(Aboul-Saleh, 2004).
Research in the field of co-morbidity has highlighted some potential approaches that may
lead to positive outcomes in this population. An early study by Franco et al. (1995)
indicated that peer led token economies base on behavioural principals were associated
with a decrease in negative behaviours and an increase in patient participation in group
activities. Further research also provided some evidence for contingency management
consisting of both incentives and disincentives to prevent continued illicit drug use and
there by providing positive outcomes (Griffith, Rowan-Szal, Rowark, & Simpson, 2000).
Swanson, Pantalon & Cohen (1999) indicated that motivational techniques based on
motivational interview principles were associated with increased patient treatment
retention in dually diagnosed patients. Further research found that motivational
interventions increased attendance and treatment engagement and decreased
hospitalisations in patients with co morbid depressive disorders and substance misuse.
There is also growing support and consensus for the combination of approaches such as
cognitive behavioural and motivational interviewing, and the need for integration of
treatments for those with co-morbid psychiatric and substance misuse disorders (Mueser,
et al., 2003; DiClemente, et al., 2008). Although there is some evidence for the
effectiveness of certain psychological interventions, there is still a distinct lack of
empirical research providing clear indications as to what works in the field of co-
morbidity (Baldachinno, 2007). The Scottish Model for co-morbidity is based upon 5 key
steps. These include community and social support, generic services, generic service with
some specialised function, such as the community mental health team within mental
health services, and the community drug and alcohol teams. Other steps within the model
include specialist services such as the co-morbidity led nursing services in rural areas and

8. multi disciplinary assertive outreach teams. The final step involves highly specialised
treatment resources such as regional co-morbidity units (Scottish Executive 2002).
Despite these recommendations it has been highlighted that problems with and gaps in
service provisions still persist. The co-morbid mental health and substance misuse in
Scotland study (Hodges, Taikato, McGarrol, Crome & Baldecchino 2006). Results of this
study indicated that both service providers and service users identified a number of
deficits in service provision. These included difficulties in accessing services; lack of
crisis support; lack of continuity of care; lack of access to psychological therapies;
overemphasis on medication based treatments; lack of service user involvement in care
planning; a lack of specialist services addressing antecedent issues such childhood trauma
(Hodges et al., 2006).
It is clear that there are a number of treatment interventions for opiate dependence. To
date, it would appear that substitutive and maintenance treatments with Methadone are
the most widely researched and implemented in Scotland. It is also evident that addiction
and substance use are complex disorders and involve the interaction of various biological,
psychological, psychiatric and social factors. This further highlights that there is a need
for greater variety of treatment interventions to be made available at different times
throughout the course of recovery from substance dependence. This is especially true
given the growing awareness of the prevalence of co-morbidity of mental health and
substance use disorders, and their chronic relapsing nature requiring focused and flexible
responses at different levels and tiers within health and social care. Clinical services
should view co-morbidity as the norm rather than the exception and should therefore
adopt a holistic and inclusive approach. Effective and integrated interagency and
multidisciplinary partnership working, more thorough shared assessment and service user
needs identification, and individually tailored care plans involving service users should
be the future direction. This would facilitate the development of services which are needs
led rather than service led.

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