Addictive Behaviours - Methods of modifying behaviour: Agonist and antagonist substitution

Question 1

What are the 2 components to this topic

Answer 1

• Agonist substitution: Methadone
• Antagonist substitution: Naltrexone

Question 2

Describe Agonist substitution: Methadone

Answer 2

• An agonist drug binds to a postsynaptic receptor and activates it, mimicking the effects of a substance of abuse without the harmful consequences.
• Methadone is an example of an agonist used to treat opioid addiction, such as heroin.
• It occupies the same dopamine receptors in the brain, reducing cravings and preventing withdrawal symptoms like shaking and flu-like effects.
• Unlike heroin, methadone does not produce the same ‘high’, making it safer for long-term use.
• The aim of methadone maintenance treatment is to stabilise the patient on a safe dose, which is gradually reduced over time through detoxification to achieve abstinence.
• NICE guidelines suggest starting with 10-40 mg daily, increasing up to 60-120 mg for maintenance, with each dose lasting 24-36 hours.
• Methadone is usually given orally (as a green liquid) to avoid the risks associated with needle use, and supervision is required for the first three months to ensure safe dosage and prevent misuse.
• Methadone is generally safe but can cause minor side effects like drowsiness, constipation, and sweating.
• It is unsuitable for individuals with conditions like liver disease but can be used for opioid-dependent newborns in hospital settings.

Question 3

Describe Antagonist substitution: Naltrexone

Answer 3

• An antagonist drug binds to a receptor and blocks the usual function of a substance without triggering a response.
• Naltrexone is an antagonist used to treat opioid addiction, primarily during the abstinence stage.
• It blocks the pleasurable effects of opioids, making them less rewarding and reducing relapse risk.
• NICE guidelines recommend its use for individuals who have stopped using opioids and are motivated to remain drug-free.
• Naltrexone is typically taken orally, but depot injections and implants are available in the USA and Russia.
• It is administered after 7-10 days of abstinence (after withdrawals have been experienced), with a test dose of 25 mg to ensure tolerance before the standard 50 mg daily dose is given.
• Naltrexone is also used in alcohol addiction treatment after withdrawal, alongside psychological support, and can be prescribed for up to six months.
• It helps maintain abstinence by breaking the reward cycle, blocking the ‘high’ from alcohol.
• A 380 mg depot injection is administered every four weeks, and common side effects include nausea, dizziness, anxiety, insomnia, and, rarely, liver failure or suicidal thoughts.

Question 4

When evaluating this treatment, what 3 things do you talk about

Answer 4

• effectiveness
• ethical implications
• social implications

Question 5

When evaluating the effectiveness what strengths do you talk about

Answer 5

• Methadone’s treatment retention
• Methadone’s comparison with Buprenorphine for safety
• Naltrexone’s success in reducing relapse rates
• Naltrexone’s application to behavioural addictions

Question 6

Evaluate the strength of Methadone’s treatment retention

Answer 6

P: Methadone is effective in retaining patients in addiction treatment programs, which is a crucial factor in long-term recovery.
E: NICE reviewed 31 studies, including 27 randomized controlled trials, and found that methadone users had significantly higher retention rates compared to those receiving a placebo or no treatment at all. Additionally, methadone use correlated with lower rates of illicit opioid use.
T: This suggests methadone’s effectiveness, as higher retention rates mean patients are more likely to stay in treatment, reducing the risk of relapse and maintaining progress toward recovery. Therefore, methadone’s role in improving retention supports its effectiveness in opioid addiction treatment.
C: However, methadone treatment may lead to dependence itself, creating a reliance on another substance rather than promoting complete independence from opioids.

Question 7

Evaluate the strength of Methadone’s comparison with Buprenorphine

Answer 7

P: Buprenorphine, an alternative to methadone, is considered safer due to its ‘ceiling effect,’ which limits the risk of overdose.
E: Research by Dave Marteau et al. (2015) found that buprenorphine was six times safer than methadone, as increased dosages beyond a certain point no longer intensify the drug’s effects, minimizing overdose risk.
T: While methadone is effective in patient retention, buprenorphine’s safety profile gives it an edge in certain cases, as the ceiling effect reduces the risk of overdose. However, because methadone is still more effective in retaining patients (Whelan and Remski, 2012) due to the drug feeling better when taking, suggesting that safety must be balanced with retention rates, affirming methadone’s overall effectiveness.
C: If the dosage of methadone is not carefully managed, patients may experience either insufficient relief from withdrawal symptoms or heightened risks of dependency and misuse.

Question 8

Evaluate the strength of Naltrexone’s success in reducing relapse rates

Answer 8

P: Naltrexone has been shown to reduce relapse rates in highly motivated patients when paired with close monitoring and additional support.
E: NICE reviewed 17 studies and they found that overall, naltrexone was associated with lower relapse rates for patients who were motivated and supported during treatment.
T: This suggests that naltrexone’s effectiveness is partially dependent on patient motivation and the support structures in place. In cases where patients are committed and have adequate support, naltrexone can be effective in preventing relapse, making it a viable option for specific patient groups.
C: On the other hand, naltrexone’s success relies heavily on patient motivation and consistent support, meaning it may not be effective for patients lacking these factors.

Question 9

Evaluate the strength of Naltrexone’s application to behavioural addictions

Answer 9

P: Naltrexone may also be effective for certain behavioral addictions, showing promise beyond opioid dependency treatment.
E: In a study by Tuuli Lahti et al. (2010), a sample of gamblers showed a significant reduction in gambling urges and behavior when taking naltrexone, suggesting it may help in curbing addictive behaviors outside of opioid dependence.
T: This supports the notion that naltrexone has a broader application for various forms of addiction, making it versatile and potentially effective for different types of compulsive behaviours.
C: Although naltrexone shows promise for behavioral addictions like gambling, its effectiveness outside opioid dependence is still unproven, and results may not be generalizable without further research.

Question 10

When evaluating the weaknesses of effectiveness, what do you talk about?

Answer 10

• attrition
• cross cultural comparisons
• study duration

Question 11

Evaluate the weakness of attrition

Answer 11

P: A weakness is the issue of high attrition rates, which can bias study outcomes and make data ungeneralizable.
E: Research on methadone and naltrexone often shows high dropout rates, particularly among individuals who struggle most with adherence to treatment. Studies therefore tend to gather data only from individuals who successfully remain in the program
T: This is a weakness as it means that studies may overestimate the effectiveness of the treatments, as they only reflect the outcomes of individuals who can adhere to the program. Consequently, attrition creates a skewed sample that could make the treatment seem more effective than it truly is for the general population, limiting the generalizability of results.
C: Some might argue that even with attrition, the treatment’s impact on those who remain in the program is still meaningful and can provide insight into possible success for motivated individuals

Question 12

Evaluate the weakness of cross-cultural comparisons

Answer 12

P: Cross-cultural differences pose a significant challenges as variations in treatment protocols, dosages, and support systems across countries make direct comparisons problematic.
E: Farre et al. (2002) conducted a comparative study on methadone treatment across several European countries and found notable differences in dosage, frequency of administration, and the level of social support offered to patients. These factors led to variability in treatment outcomes, suggesting that cultural and systemic differences heavily influence treatment success.
T: therefore this variability complicates the interpretation of data on treatment effectiveness, as the success rates observed in one country may not be replicable in another due to differing healthcare standards and cultural attitudes toward addiction, making it difficult to draw universally applicable conclusions about treatment efficacy.
C: However, examining treatment effectiveness across different cultures could highlight which practices are most effective and adaptable, potentially leading to improved treatment protocols worldwide.

Question 13

Evaluate the weakness of short study durations

Answer 13

P: The short duration of most studies on methadone and naltrexone treatment effectiveness limits the understanding of long-term outcomes, especially regarding relapse rates years after treatment.
E: Many studies on methadone and naltrexone only follow participants for about a year after treatment, and although short-term results often look promising, they may not reflect long-term success in preventing relapse.
T: This limited follow-up period raises concerns about the accuracy of claims regarding treatment effectiveness, as relapse may occur well beyond the study’s duration. Therefore, data that only shows short-term effectiveness could be misleading, failing to capture the potential long-term challenges and risks associated with opioid dependence recovery.
C: It could be argued that while short-term studies have limitations, they are still valuable for understanding immediate outcomes and patient responses to treatment, which are essential for initial treatment evaluation.

Question 14

When evaluating the ethical implications, what do you talk about?

Answer 14

• side effects + risk of overdose
• methadone creates a dependency, removing participant’s free will to withdraw from treatment

Question 15

Evaluate the ethical implication of side effects and risk of overdose

Answer 15

P: One ethical issue with using methadone is the potential for serious side effects and overdose, especially when combined with other substances.
E: Methadone can interact with substances like alcohol and antidepressants, causing respiratory issues and potentially leading to life-threatening complications. The Office for National Statistics reported that methadone was linked to 429 deaths in the UK in 2013, underscoring the risk of fatal overdose if not properly managed.
T: These risks raise ethical concerns about patient safety, as individuals seeking treatment for addiction may be exposed to significant health hazards, particularly if not closely monitored. The risk of fatal side effects can be seen as ethically questionable, as it may put vulnerable patients in harm’s way rather than providing them with safe recovery options.
C: However, it is far safer than allowing patients to continue opioid addictions and risk contradicting diseases related to needle exchange such as HIV

Question 16

Evaluate the ethical implications of dependency and long term use

Answer 16

P: One ethical concern is methadone treatment may replace one addiction with another, as many individuals remain on methadone for prolonged periods without achieving full recovery.
E: Critics argue that methadone merely substitutes one substance for another, and without adequate support, patients often fail to transition to detoxification and abstinence stages. This can lead to long-term dependency on methadone, prolonging a cycle of addiction rather than truly addressing it.
T: Therefore by keeping patients on a drug indefinitely, it can be seen as failing to provide genuine recovery opportunities, as it may trap individuals in a dependency cycle that benefits treatment providers financially rather than supporting full rehabilitation. This also takes away the right to withdraw from treatments as participants become over dependent on methadone, further highlighting how unethical this treatment is
C: However, these programmes are highly accessible and easy to follow as they require minimal commitment. It can help addicts detach from drug culture, and put them in a better place in order to deal with abstinence

Question 17

When evaluating the social implications, what do you talk about?

Answer 17

• cost to society
• impact on criminality
• community concerns and stigma

Question 18

Evaluate the social implication of the cost to society

Answer 18

P: One social implications is the financial cost which includes not only the direct costs of methadone programs but also related expenses, such as providing benefits to individuals who remain unable to work.
E: A report by the Centre for Policy Studies (Gyngell, 2011) argued that methadone treatment is an “expensive failure,” emphasizing the high costs associated with maintaining methadone programs for the estimated 320,000 problem drug users on benefits. Gyngell suggested that funding abstinence-based rehabilitation units would be a more effective use of resources.
T: The financial burden may raise questions about whether methadone is a sustainable long-term solution or whether it perpetuates dependency without achieving true rehabilitation. Perhaps alternative treatments as Gyngell suggests should be invested instead
C: However, the charity DrugScope has challenged these claims, arguing that the report overestimates the cost of methadone programs. The National Audit Office has noted that methadone treatment offers good value for taxpayers by helping many individuals manage their addiction and reintegrate into society, which may ultimately reduce costs related to healthcare, crime, and social services.

Question 19

Evaluate the social implication of the impact on criminality

Answer 19

P: One social implication of methadone treatment is that it may reduce the criminal behavior associated with addiction by stabilizing individuals and reducing their need to commit crimes to fund drug use.
E: According to a report by the National Treatment Agency (2009), methadone treatment can cut rates of offending by half when individuals are in treatment. By reducing criminal behavior, methadone programs can create a safer environment for communities and decrease the social costs associated with drug-related crime.
T: Therefore a reduction in criminality suggests that methadone treatment could have positive social benefits by lowering the demand for law enforcement and reducing the stress that crime places on local communities
C: However, the Centre for Policy Studies (Gyngell, 2011) report claims that drug-related reoffending has not decreased, suggesting that methadone treatment alone may not fully address the complex social issues associated with addiction and that additional strategies may be required to reduce crime rates effectively.

Question 20

Evaluate the social implication of community concern and stigma

Answer 20

P: Methadone treatment centers raise concerns about crime and antisocial behavior in local communities, as some believe these centers attract groups of addicts, potentially leading to an increase in crime or unwanted social behavior in the area.
E:Despite these concerns, research by Susan Boyd et al. (2012) in Baltimore, USA, found no significant increase in crime rates around methadone treatment centers, indicating that the centers do not necessarily lead to higher levels of crime or disruption in the surrounding community. This research suggests that community fears may be based more on stigma and perception than on actual outcomes.
T: Therefore, by dispelling myths about crime increases around treatment centers, communities may become more supportive of these centers, which could help individuals access the support they need without facing social judgment or resistance.
C: However, the stigma surrounding methadone clinics remains a real social issue, as public perception can still affect community acceptance. Even if data does not show increased crime, community members may continue to feel wary about the presence of addiction treatment facilities in their neighborhoods, which could impact local support and funding for these programs.