A Drug Free Approach to Treatment – Cultural/Social Aspects and Follow-Up Studies: the case of ‘San Patrignano’ Therapeutic Community

The dispute between those who seek to accommodate drug misuse (whose opponents dismiss them as ‘fatalists’) and those who seek to enable a return to drug-free lifestyles (whose opponents dismiss them as ‘dreamers’) has long existed in many countries. This paper, originally presented by its author, verbally in Italian at a conference in Rimini, Italy, targets this dispute, and expands on it by looking at the related social, cultural, and sociological factors. As the author explains, drug addiction can be seen as a ‘disease of the soul’ – and in this setting, detoxification is the least of the problems. After discussing and characterising this change of paradigm, the author supports it by presenting research results based on the experiences of present and former residents of the San Patrignano Community, the facility on which this paper is based. Introduction and Background The research described in this paper is substantially based on experience within the San Patrignano Therapeutic Community, located in Rimini, on the Adriatic coast of Italy. San Patrignano Community houses and interacts with almost 1,500 residents at any one time, and since it’s founding in 1978 has served more than 18,000 people, at no charge. The resident group is diverse, and includes families with children. Some residents are HIV positive. The community provides medical care through a sizeable hospital within the site. Residents receive training to prepare them for possible employment in diverse trades and professions. The community philosophy is perhaps best summed up in the words of the founder, the late Vincenzo Muccioli, who said: “Among the problems that affect the drug addict, drug use is the least relevant. The core of the problem is not drugs, nor the abstinence crisis: it is the human being with his fears and the black holes that threaten to suck him in. That is why I do not like to say nor hear that ours is a community for drug addicts. Ours is a community for living, where you can restart after years spent as a social outcast. Ours, if we really need a definition, is a community against social marginalisation. ” In favour of a cultural approach to drug addiction In this paper, the author will focus on the issue of drug addiction in cultural terms rather than using the antiquated idea of a medical vs. social approach to drug addiction (in this context, this opposition between medical and social made sense 25 years ago when, for instance, it was important to legitimise and show the value of the work done by therapeutic communities). Today, if one assumes that the pioneering stage of intervention can be considered as ‘behind us’, the clash is reduced between ‘medical approach’ and ‘social approach’. But the clash still exists: it is primarily a cultural clash between the tendency to consider drug addiction as a lifestyle choice, and the tendency to approach drug addiction as a disease that highlights the drug-free condition. In this sense, the cultural dimension cuts across the medical and the social approaches. A drug-free culture may influence physicians and other relevant workers’ interventions; similarly, a culture that is bound to the idea of drug addiction as a lifestyle (often inspired by what is generally known as “harm reduction”) may be a source of inspiration for social intervention, possibly implemented by professionals who are typically present in the social field (e.g. sociologists and social workers). Given this general distinction, and since a clear stance should be expressed by everyone addressing these issues, the preference of this author is to adhere to the drug-free approach: the approach of “sobriety” to quote a favourite term of Alcoholics Anonymous. Against this background, some of the main implications of this approach will be considered within the space limitations of this paper. Choosing a drug-free approach means that one considers drug addiction to be a non-chronic disease, despite being a recurring one. This implies that the objective is to abstain from substance use and to be able to live without drugs throughout time (i.e. living permanently without drugs). The first implication of this choice can be characterised as follows: it is possible to stop taking drugs and drug addicts are not chronic patients. Obviously, this does not mean that relapses do not occur and that the way out of drug addiction is linear. On the contrary, relapses and interruptions are the rule: since these ‘incidents’ are ever present, this supports the suggestion that drug addiction is not a chronic disease. Unfortunately, as is too often the case, drug addicts are considered unrecoverable (i.e. terminally ill patients). Clearly, in this type of scenario, the objective is not to improve the quality of life of those who continue to be drug addicts; rather, the objective is to find a way out of drug addiction. In radical terms, the drug-free approach combines the idea of quality of life with the idea of living permanently without drugs (In contrast, the harm reduction approach focuses only on the improvement in the quality of life of the addict, regardless of the drug-free condition and regardless of the impact on the rest of the community at large. The second implication concerns the distinction between different types of drugs. If one opts for a drug-free approach, the distinction between soft and hard drugs becomes less significant. This is not to say that there are no differences between substances but, this aspect is irrelevant for those who choose an approach aiming at sobriety and who consider sobriety to possess value. In this sense, the distinction between different types of drugs is only significant with a view to better targeting interventions, whose main objective should be to achieve a drugfree condition (for instance, in case of drug addicts who do not perceive themselves as such, it would be necessary to implement outreach strategies to act upon this very frequent situation today). The third implication relates to the duration of treatment and its minimum prerequisites. Considering minimum prerequisites first, without going into detail about different modes of intervention, once the drug-free approach is adopted, the aim of the course of treatment should also include abstinence from drug use and monitoring that abstinence should be maintained throughout treatment. From this perspective, even when alternative medications are employed (e.g. methadone), it is necessary to ensure that no drug be used together with methadone (in fact, this is something more than likely to occur, regardless of the norms in place, as can be testified by people working in this sector). In sum, treatment cannot be compatible with the use of illegal substances. From this perspective, the course of treatment is of paramount importance, not only because it aims at living permanently without drugs once it has been completed, but also because the subject is in a drugfree condition for the entire duration of the treatment itself (in many therapeutic communities this means that even methadone-based treatment is excluded, with only few exceptions and for a short period of time). On the issue of treatment duration, in this author’s view, drug addiction is a disease (suffering) of the soul (in practical terms, this means that physical detoxification is the least of the problems, and to achieve behavioural change, it is not enough to stay drug-free throughout time, unless it is associated with a certain “internal” dynamic). If drug addiction is considered a disease of the soul, the timing of treatments would be the same as what would be required for psychoanalysis. However, the author is not suggesting that people on drugs need to undergo psychoanalysis (indeed, a competent analyst would never accept to treat anyone on drugs); but it should be recognized that it takes years to quit drug addiction, insomuch as a short-term, analytically-oriented psychotherapy (i.e. not psychoanalysis proper) would normally last no less than three years. Thus, to better clarify the position, it is conceded that “it is true that there is a way out of drug addiction, but it is equally true that it is a long and hard way to go” and that in order to be fruitful, possibly it should be drug-free. Finally, the fourth implication of a drug free approach necessarily regards follow-up. Indeed, choosing this type of approach means that the first aspect to be assessed is abstinence from substance use throughout time – only after this will reintegration and social behaviour be evaluated. On the issue of assessment in general, and follow-up or outcome evaluation in particular, a key point worthy of further consideration is that results need to be evaluated starting with an assessment of the drug-free condition, possibly by means of scientific trials, such as hair strand analysis, which makes it possible to trace back up to several months. In the particular case of outcome evaluation, some fundamental integrations are essential, including programmes’ retention factor or, even prior to that, enrolment selection criteria in individual therapeutic programmes. These are a few of the implications involved in a drug-free approach. Building on extensive field experience (spanning nearly 30 years), the aim of this paper is to provoke more widespread appreciation of this paradigm , and to establish parameters, as a first step towards systematizing and evaluating the evidence (possibly scientific evidence) around the paradigm. On a cautionary note, this shared knowledge should not be entangled in political or ideological confrontations and reductionism, which too often, especially in the Italian context, have characterised the debate over drug addictions. The “Beyond the community” research project: methodological aspects and findings