Efficacy of group therapy as an add-on option to medicinal management for relapse prevention among patients of opioid dependence disorder

 

 

Abstract               Rational of the study: Opioid dependence has become a major addiction problem in India. Among all the available treatment options for relapse prevention, medical management and group therapy for relapse prevention are regularly proven by research to be effective. However the group therapy has not been employed very frequently. We intended to study the benefits of adding group therapy to medical management for relapse prevention. Methodology: A total of 86 patients of opioid dependence, diagnosed using DSM-IV-TR, were chosen through random sampling from various rehabilitation centres of Indore district. Of these 86, 43 patients continued their routine medical management for relapse prevention and the rest 43 were given add on group therapy along with medical management for relapse precention. A follow up was done over 9 months. Result: The mean age was 22.6 years and all were educated. Relapse rates in medicine alone group (n=43) was found to be 86.05% (n=37) whereas that in the group of group therapy and medicine (n=43) was found to be 20.93% (n=9). Conclusion: Group therapy was found to be an effective add-on approach for the treatment for opioid dependence and relapse rate were found to be very low.

Key Word: Group Therapy, Opioid Dependence

 

 

INTRODUCTION

The prevalence of opioid dependence is increasing day by day world over and especially in India. The young adults and adolescent population is at special high risk and prevalence of crime in such population is very coommon.^1,2 Research indicates that opioid use and crime are associated and develop together. Amongst opioid-using criminals, the need for opioids may cause crime on a day to day basis³. Opioid dependence is characterized by a powerful, compulsive urge to use opioid drugs despite adverse consequences in life. Opioid changes the chemistry of the brain that lead to drug tolerance and that is why Opioid has a high potential for causing dependence. Opioids can lead to physical dependence within a short time, as little as 4-8 weeks⁴. According to the American Medical Association (AMA), an estimated 3 to 19 % of people who take prescription pain medications develop an addiction to them⁵.Opioid dependence can cause life-threatening health problems, including the risk of overdose⁶. Opioid withdrawal syndrome is a life-threatening condition resulting from opioid dependence⁷. In chronic users, the abruptly stopping use of opioids lead to severe symptoms, including lacrimation, rhinorrhea, piloerection “goose flesh” myalgia, diarrhea and photophobia, insomnia, autonomic hyperactivity and yawning. Because these symptoms are severe it necessitates using opioids to prevent withdrawal⁸.There are many treatment options i.e. Medical assistance therapy (for physical dependence), 12 step therapy, counseling and modern Psychotherapy (for mental dependence). WHO (2004) indicates that Opioid use disorders typically require long-term treatment and care with the goal of reducing risks for the individual, reducing criminal behaviour, and improving the long-term physical and psychological condition of the person⁹. Studies suggested that inpatient treatment was found effective with low rate of relapse followed by group therapy, individual therapy and self-help group participation¹⁰ but many studies indicate that group therapy is not as successful treatment as compared to medicine assistance therapy^11,12. As per the addictive properties of Opioid- “Opioid dependence is more than a physical dependence on drugs”. Even after detoxification, followed by 13 weeks of Rehabilitation, individual with Opioid dependence still are at high risk for relapse due to n number of reasons as poor stress coping skills, peer pressure, familiar locality and personality traits etc. These things can create a strong ongoing urge to use it again. Individuals who are struggling with Opioid Dependence need to confront the behavioral, psychological, and emotional challenges that are known to contribute to the development of an addiction or dependence on any substance. In order for effective treatment, patients must obtain support and treatment for these factors. By including group therapy into a patient’s treatment plan, patients can address and process the underlying causes of their dependence. Group therapy is a kind of psychotherapy that involves a group of people with the same problems which is conducted by a trained mental health worker (Psyhotherapit) in order to find a concrete solution. There can more than one psychotherapist and can be named as primary therapist and secondary therapist or co-therapist. The broader concept of group therapy can be taken to include any helping process that takes place in a group, including support groups, skills training groups (Mindfulness, Stress management, Anger Management, Social Skills Training etc), self help groups (AA/NA/CA/Al Anon group etc) and Psycho-educational Groups¹³. Group process explicitly utilizes a mechanism of change by developing, exploring and examining interpersonal relationships within the group. Yalom et al. investigated and proposed a number of therapeutic factors of groups i.e. Universality, Altruism, Instillation of hope, Imparting information, Corrective recapitulation of the primary family experience, Development of socializing techniques, Imitative behaviour, Cohesiveness, Existential factors, Catharsis, Interpersonal learning, Self-understanding¹⁴. All above-mentioned therapeutic factors increase the level of self-acceptance, objectivity and insight about illness related behaviour. Patients try to imitate successful behaviour with adaptation of their character defects through interpersonal learning and catharsis by any one of group member. So exposures of group therapy increase the level of insight in the patients but in contrary, there is a group of research that indicates “Group therapy is not as successful treatment option in Opioid dependence syndrome as depression, PTSD and other stress related disorders included with addiction^{13, 15.} It may be possible because in the field of addiction treatment there has been a tendency to eschew dynamic understanding for simple descriptive diagnosis based on verifiable criteria. This tendency has been accompanied by a focus on behavioral treatments that can be reliably evaluated using objective outcome measures and by an immense research effort to understand the biology of addiction¹⁶.The efficacy of group therapy on opioid dependence is a questionable statement .So present topic was chosen for investigating the effect of Group Therapy on Opioid Dependence along with six month of follow up.

METHODOLOGY

All the patients being treated for opioid dependence, as diagnosed by DSM IV TR criteria, in various rehabilitation centres of Indore, after completion of their initial medical management for managing withdrawal symptoms were given an option of either opting for additional group therapy along with the medical relapse management for preventing relapse or only the medical management as per the routine management plan. After explaining the nature of the study to all the patients, 43 patients belonging to each of the group (n=86) were recruited for the study after obtaining a written informed consent. Group A (n=43) had patients opting for group therapy for relapse management along with the traditional medical management for opioid relapse prevention. The other group, Group B (n=43) had patients opting for the traditional medical management for opioid relapse prevention without the group therapy activities. The exclusion criteria were psychosis, imminent suicide risk, organic brain disorders or diagnosis of other drug dependence (Except Nicotine). Pre-Post Experimental Control Group Research design has been used to explore the cause effect Group therapy on opioid relapse prevention in present research. Group A participants, underwent a total of 56 group sessions of 1 hour each over a period of 8 weeks. These group sessions were based on Approaches of REBT and core concept of Living Sober book of Narcotics Anonymous. The sessions were conducted from morning 8 am to 9am on every day of the week. The same therapist guided all the sessions as per the attached schedule. (Table1,2). Along with these sessions, they were on weekly followups with a Psychiatrist and were maintained on medical relapse prevention regime of Naltrexone 50mg ones a day. Group B on the other hand were on the medical management alone. After the duration of research, all participants were followed up monthly until 9months by individual and family interview.

 

Table 1: REBT Modules for treatment of addiction

Table 2: Living Sober book, NA Recovery Literature

 

RESULTS

The mean age of 22.6 years (n=86) and all the participants were educated at least until higher secondary school. The number of patients who remained in remission after the end of 9 months was noted for each of the groups and the respective relapse rates were assessed. The relapse rates were 20.93% (n=9) in the group A as compared to 86.05% (n=37) in the group B.

 

DISCUSSION

The study highlights the efficacy of group therapy as an add-on intervention to the current traditional medical measures for relapse prevention. It was seen that the group receiving add on group therapy intervention along with the traditional medicinal approach had far less relapses as compared to the group receiving only medicinal approach. In a group therapy session, participants gain information through sharing their experiences which improves the cohesiveness of a group. Basically Group therapy sessions are based on specific themes related to the solution of the problems that occur due to opioid dependence. People participating in the group can observe that others are going through the same thing, which can help them relate. By observing someone successfully coping with a problem, other members of the group can see that there is a hope for recovery. As each person progresses, they can, in turn, serve as a role model and support figure for others. This can help foster feelings of success and accomplishment. Such type of attitude and insight about the illness and behaviour, allows people to receive the support and encouragement of the other members of the group. Group therapy facilitates altruism to group members through imparting information which boost self-esteem and confidence of the group members. By sharing the experience within the session, other members can identify the issues preventing the recovery and get insight also to resolve the issues. Problems after Opioid dependence are often associated with significant difficulties in the personal lives of the users and/or of their families. These may include breakdown in family life and personal relationships, money problems, poor educational achievement and loss of employment and many others. Other forms of social support and reintegration interventions may be required if treatment of drug addiction is to be effective in the long-term (17). So in such type of cases, group therapy works as a tool of reinstallation of hope because individual with opioid dependence loose the hope for recovery and family starts refusing help for them. They feel hopelessness but they cannot identify their problem behaviour and negative feelings while leading their life. After participation in group therapy, individual with Opioid dependence can identify their character defects and negative feeling that helps in the process of recovery in the stage of maintenance. Every group therapy session starts with a problem related with the addiction and ends with solution. Results obtained by other research works confirm the results of the current study. Recently Mindfulness based group therapy has been proven to be an admissible treatment. (18,19,20,21) Every group therapy session spreads a new insight for problem solving in the life. As per cognitive ideology of addiction “Every addict lacks problem solving skills and hence rely on regressive behaviour in his life”. Participating in group session makes them aware about the behaviour pattern of an addict and also suggests them adequate solution of the problem. Over a period of time they will develop new problem-solving skills which help in reducing the probability of relapse. (22,23) The efficacy of group therapy on the addiction has been proven by many researches (10,24,25,26). During the process of recovery participant understand that the craving for substance and feelings of obsession towards drugs is a normal process of recovery and they need to deal with such thoughts in the process of recovery.

 

CONCLUSION

Group therapy empowers a person with opioidd dependence to cope up with the problems of drug depedence and leads to a better relapse rates. All the patients undergoing medical management for opioid dependence should be encouraged to initiate the group therapy as well for better results. A similar study on a larger sample size would be more conclusive.

               

REFERENCES