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Commentaries
and clinical staff may focus either deliberately or unintentionally upon what is perceived to be the main illicit problem drug and under-rate the use of other substances. The extent and severity of heavy drinking among drug misusers points to the need to develop programmes and interventions that are designed specifically to tackle alcohol-related problems in this client group. Declaration of interests None. Keywords cocaine, heroin, polydrug use, alcohol, treatment outcomes. MICHAEL GOSSOP
National Addiction Centre, King’s College London, London SE5 8AF, UK. E-mail:
[email protected] References 1. Staiger P. K., Richardson B., Long C. M., Carr V., Marlatt G. A. Overlooked and underestimated? Problematic alcohol use in clients recovering from drug dependence. Addiction 2012; 108: 1188–93. 2. Gossop M. A web of dependence. Addiction 2001; 96: 677–8. 3. Liebson I., Bigelow G. A behavioural pharmacological treatment of dually addicted patients. Behav Res Ther 1972; 10: 403–5. 4. Gossop M., Marsden J., Stewart D., Treacy S. A prospective study of mortality among drug misusers during a 4-year period after seeking treatment. Addiction 2002; 97: 39–47. 5. Gossop M., Browne N., Stewart D., Marsden J. Alcohol use outcomes and heavy drinking at 4–5 years among a treatment sample of drug misusers. J Subst Abuse Treat 2003; 25: 135–43. 6. Gossop M., Marsden J., Stewart D., Rolfe A. Patterns of drinking and drinking outcomes among drug misusers: one year follow-up results. J Subst Abuse Treat 2000; 19: 45–50. 7. Harris D. S., Everhart E. T., Mendelson J., Jones R. T. The pharmacology of cocaethylene in humans following cocaine and ethanol administration. Drug Alcohol Depend 2003; 72: 169–82. 8. Gossop M., Manning V., Ridge G. Concurrent use of alcohol and cocaine: differences in patterns of use and problems among users of crack cocaine and cocaine powder. Alcohol Alcohol 2006; 41: 121–5. 9. Gossop M., Manning V., Ridge G. Concurrent use and order of use of cocaine and alcohol: behavioural differences between users of crack cocaine and cocaine powder. Addiction 2006; 101: 1292–8.
PROBLEMATIC ALCOHOL USE IN CLIENTS RECOVERING FROM DRUG DEPENDENCE—TIME TO ADJUST OUR FOCUS The systematic review by Staiger and colleagues [1] casts the spotlight on alcohol use as a potential impediment to © 2013 The Author, Addiction © 2013 Society for the Study of Addiction
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recovery from illicit drug dependence. They argue, justifiably, that treatment outcome research needs to place greater emphasis on assessing the extent of alcohol use to establish whether drug substitution is occurring and to determine whether alcohol use increases the risk of relapse to primary drug use. The question of whether treatment services are giving enough specific attention to alcohol use is also raised. One of the many challenges facing treatment outcome research is how best to measure treatment success or failure given the complexity of drug dependence. It is well recognized that drug dependence is often a chronic relapsing condition, associated with polydrug use, comorbid psychopathology, physical health problems, poorer social functioning, high levels of unemployment and legal problems. How, then, do researchers determine what to assess and what to forgo in balancing the need for information about treatment outcomes, with the burden placed on study participants? A common method for outcome studies to streamline the information collected is to classify participants according to the primary drug for which they are seeking treatment. This approach has appeal, as drug classes differ in their neurophysiological and psychological effects, and framing studies of illicit drug use in this way aids the interpretation of analyses based on drug use typologies [2]. Unfortunately, as found by Staiger et al., the data reported about other drug use are often fairly limited, making the impact of specific patterns of polydrug use on treatment outcome hard to determine. Reassuringly, a recent analysis of 10-year trajectories for heroin, cocaine and methamphetamine users demonstrates that group descriptions do appear to present valid information about drug use patterns [2]. Using growth modelling, the study found declining primary drug levels for heroin and methamphetamine users and fairly consistent levels over 10 years for cocaine users. Nonprimary drug use remained at consistently low levels or reduced in parallel with the primary drug. The study lends support to the validity of longitudinal analyses based on primary drug classifications but, as the authors suggest, a focus on individuals who deviate from the general patterns may be beneficial in identifying strategies for prevention or intervention. There are many reasons why alcohol use warrants more detailed attention, both from a research and treatment perspective. First, alcohol’s legal status and common usage in most western societies may cause illicit drug users to underestimate the risks associated with alcohol use. This is certainly implied by the high levels of alcohol use seen among treatment entrants [3,4]. Alcohol use is also strongly associated with an increased risk of fatal and non-fatal heroin overdose [5], suicide [6] and motor vehicle accidents [7]. Given the Addiction, 108, 1194–1200
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high rates of hepatitis B and C seen among injecting drug users, alcohol use is also problematic in that it exacerbates the progression of liver disease [8]. Illicit drug users who use alcohol are also more likely to be victims of physical violence [9]. Indeed, the harms associated with alcohol use among illicit drug users are so pervasive it could be argued that drug users should be educated about these, irrespective of their current alcohol use patterns. In attempting to address the question of whether or not alcohol use post-treatment leads to relapse to illicit drug use, Staiger and colleagues [1] give no consideration to the psychiatric comorbidity that could be driving this drug use behaviour. This would clearly need to be explored in future studies attempting to understand the mechanisms involved in alcohol use triggering relapse to illicit drug use. The complex nature of drug dependence, with its high levels of polydrug use and psychiatric comorbidity, is a challenge to treatment providers and researchers worldwide. The use of relapse prevention strategies, tailored for the individual to reduce the likelihood and severity of relapse, has been an important cornerstone of drug treatment for decades [10]. Research that improves our understanding of the processes involved in relapse is to be encouraged. An interesting development in recent times has been the introduction of mindfulness-based relapse prevention. Mindfulness is a trans-diagnostic approach that may be very well suited to illicit drug users, given their high levels of comorbidity. In addition to improving the focus on alcohol use, perhaps future treatment outcome studies should assess factors such as distress tolerance and emotion regulation skills, which cut across diagnostic boundaries and have implications for treatment. Declaration of interests None. Keywords alcohol, illicit drugs, mindfulness, polydrug use, relapse, treatment outcomes. JOANNE ROSS
Senior Lecturer, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia. E-mail:
[email protected] References 1. Staiger P. K., Richardson B., Long C. M., Carr V., Marlatt G. A. Overlooked and underestimated? Problematic alcohol use in clients recovering from drug dependence. Addiction 2012; 108: 1188–93. 2. Brecht M. L., Huang D., Evans E., Hser Y.-I. Polydrug use and implications for longitudinal research: ten-year trajectories © 2013 The Author, Addiction © 2013 Society for the Study of Addiction
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for heroin, cocaine, and methamphetamine users. Drug Alcohol Depend 2008; 96: 193–201. Gossop M., Browne N., Stewart D., Marsden J. Alcohol use outcomes and heavy drinking at 4–5 years among a treatment sample of drug misusers. J Subst Abuse Treat 2003; 25: 135–43. Stapleton R. D., Comiskey C. M. Alcohol usage and associated treatment outcomes for opiate users entering treatment in Ireland. Drug Alcohol Depend 2010; 107: 56–61. Darke S. The Life of the Heroin User. Typical Beginnings, Trajectories and Outcomes. New York: Cambridge University Press; 2011. Harris E. C., Barraclough B. Suicide as an outcome for mental disorders. Br J Psychiatry 1997; 170: 205–28. Kelly E., Darke S., Ross J. A review of drug use and driving: epidemiology, impairment, risk factors and risk perceptions. Drug Alcohol Rev 2004; 23: 319–44. Zakhari S., Li T. K. Determinants of alcohol use and abuse: impact of quantity and frequency patterns on liver disease. Hepatology 2007; 46: 2032–9. Marshall B. D. L., Fairbairn N., Li K., Wood E., Kerr T. Physical violence among a prospective cohort of injection drug users: a gender-focused approach. Drug Alcohol Depend 2008; 97: 237–46. Hendershot C. S., Witkiewitz K., George W. H., Marlatt G. A. Relapse prevention for addictive behaviors. Subst Abuse Treat Prev Policy 2011; 6: 1–17.
ALCOHOL USE FOLLOWING DRUG TREATMENT: MORE THAN JUST A RISK FACTOR? The review conducted by Staiger and colleagues [1] draws attention to a commonly observed problem among addiction treatment clients: alcohol use that impedes recovery from drug use. One of the main conclusions from the review is that the role of alcohol use in drug recovery is woefully understudied. Importantly, this problem has been described in the literature for 10 years [2], yet only 13 of 576 peer-reviewed papers met the key inclusion criteria of being a drug treatment study that reported alcohol use before treatment, at the end of treatment and at some point following treatment. Correspondingly, there is little research on the role of drug use in recovery from an alcohol use disorder, even though the data suggest that drug dependence predicts alcohol dependence recovery significantly [3]. Furthermore, models of alcohol and drug relapse have generally not included other contemporaneous substance use as a risk factor in the relapse process [4–7]. The results from the Staiger et al. [1] review, which provided support for the hypothesis that alcohol use increases the risk of relapse to drug use, would suggest that this is a serious omission. In my view, three questions need to be addressed in order to move the research forward and help clients in recovery from alcohol and drug use disorders. First, the authors distinguished alcohol use from the ‘primary Addiction, 108, 1194–1200
