Medications in perspective

The clinical goal-oriented approach requires the therapist to be clear about the focus of their specific clinical objectives at each phase of the treatment process. A typical treatment plan involves three primary clinical objectives:

• drug and psychosocial stabilization

• detoxification

• prevention of relapse or recurrence.

Substitution treatments, when available, not only allow time for stabilization to occur but also time to prepare for the later objectives. As the patient progresses from substitution through detoxification to abstinence, the focus sequentially shifts from one goal to the next. Stabilization itself may be either short term with the primary goal of terminating drug use 'on top' of the prescription, or longer term where it is commonly known as maintenance. The goals of maintenance are either psychosocial stabilization in preparation for detoxification, or the more limited goal of harm reduction in a patient in whom only partial psychosocial stabilization is achievable in the foreseeable future. Unless a sufficient degree of stabilization has been achieved prior to detoxification, the chances of a successful detoxification are strictly limited. The harm-reduction goal has generated much controversy, but one of its major benefits is the reduction of spread of HIV and hepatitis B and C among injecting drug users. In this group stable long-term treatment is preferable to repeated cycles of premature discontinuation followed by relapse to uncontrolled drug use. Careful monitoring is required to ensure that patients do not continue to use on top of their prescription. Such use is treated with focused pharmacological and psychological interventions, and ultimately (if appropriate) with discharge from substitution treatment if insufficient progress is made.

Even when substitution treatments are not available, treatment of the addiction will still involve these same three clinical objectives. Drug stabilization prior to detoxification involves ironing out the fluctuations in day-to-day use, and following detoxification involves stabilizing the desires or tendencies to use the drug (e.g. craving and urges). In both cases the goal is to ensure that drug use becomes independent of mental state and circumstances.

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