Practical Implications

While the results of the studies in this thesis did have interesting theoretical implications, the primary goal of this project was to explore the potential of methods for integrating drug withdrawal expectancies into clinical addiction interventions. As discussed in detail above, it seems likely that addicted individuals have such strong beliefs about withdrawal and abstinence that any attempts to influence these beliefs purely by verbal means (e.g. in psychotherapy) would have little effect on the experience of withdrawal symptoms. However some of the results from this project did have practical implications for addiction interventions that are worth discussing.

7.3.1 Dose Tapering

The findings from Study 5 have important implications for dose tapering practices in a clinical setting. First, they indicate that standard dose tapering practices– where

patients are made aware of any dose reductions via verbal and contextual cues – are likely to lead to greater withdrawal symptoms via the creation of expectancies of withdrawal that actually exacerbate withdrawal symptoms. Second, they suggest that blinding patients to dose reductions may be effective at reducing these placebo withdrawal symptoms. These findings are noteworthy because withdrawal symptoms are an important predictor of relapse to illegal drugs, dropout during a dose taper, or cessation of tapering (Calsyn, Malcy, & Saxon, 2006; San et al., 1989). As such, any procedure which could reduce withdrawal symptoms could potentially improve the chances of patients undergoing a dose taper of successfully transitioning to a drug-free state.

One way to implement these findings in clinical practice would be to offer patients who are considering undertaking a dose taper the option of voluntary blinding.

Voluntary blinding would involve the patient electing to have their dose reduction schedule hidden from them. Their prescribing doctor could decide on the exact details of the dose reduction schedule and give instructions to dosing staff in the pharmacy, clinic, or dispensary where the patient is collecting their dose not to make patients aware of their dose or any dose changes during the dose taper procedure.

Furthermore, contextual cues that would otherwise indicate dose reductions could be removed. For example, by diluting methadone syrup with a strong-tasting cordial or fruit juice, taste cues and cues relating to volume of liquid in each dose could be masked from participants. This would remove all signals that their dose was being reduced and therefore would also remove the opportunity to generate any

expectancies of withdrawal that might lead to placebo withdrawal effects. Such a procedure has two advantages. First it would be ethical: patients would be voluntarily surrendering knowledge of dose reductions, with the understanding that they can end

the blinding at any time and find out their dose. Second it would be a very simple and inexpensive procedure to carry out.

Another advantage of this procedure is that patients could be transitioned to a completely drug-free state under blind conditions. For people who have been on a drug-replacement therapy like methadone for a long time the drug can hold a central place in their lives, to the point where the idea of not taking it is difficult to imagine, and a source of great anxiety (Syvertsen et al., 2010; Vaillant, 1988). For these

patients the expectancy of negative effects upon discontinuation is very high, which is perhaps one of the reasons why patients often relapse at the final stages of a dose taper (Calsyn et al., 2006), despite the fact that their dose of methadone they are maintained at is so small that discontinuation should cause only mild physical withdrawal symptoms (Schweizer, Rickels, Case, & Greenblatt, 1990). With blind dose tapering these issues could be removed. The patient could be transitioned to 0 mg and kept on a 0-mg dose for several weeks. They could then be informed that they have been totally drug free for several weeks. Provided that they had been coping normally during those weeks of oblivious abstinence, this could potentially be empowering, and could help to demystify the over-inflated importance of the drug in the minds of the users.

7.3.2 Open Label Interventions

The fact that caffeine withdrawal reduced significantly in the Told Decaf conditions in Studies 1, 2, and 3 in the absence of conscious expectancies suggests that relief from withdrawal can be conditioned to neutral stimuli associated with consumption of an addictive drug. In recent years much research attention has been devoted to investigating open-label placebo effects, where placebo effects are observed when participants are given a placebo and are told openly that it is a

placebo. In most cases open-label placebos are administered with an accompanying

‘rationale’, that is, with instructions that indicate that placebo effects can lead to clinical improvement, rather than that the placebo will do nothing (e.g. Kaptchuk et al., 2010). Administering a placebo with this form of instruction may create conscious expectancies of symptom improvement in the mind of patients similar to the

expectancies generated by a regular (i.e. ‘non-open-label’) placebo. In Study 3 participants indicated that they believed there was little chance that decaf would reduce their withdrawal symptoms. Yet when they were given decaf, it did reduce withdrawal. Thus Study 3 suggests that presenting addicted individuals with stimuli associated with drug use may reduce withdrawal symptoms even without verbally instructing participants that it will do so. This raises the possibility that open-label placebo interventions – where patients are exposed to the stimuli surrounding drug use – may be effective at reducing withdrawal even without an accompanying rationale. However, as mentioned in Chapter 1 and above, there are studies where exposure to stimuli surrounding drug consumption lead to compensatory effects that actually make withdrawal symptoms more pronounced. Further research into which drugs are amenable to open-label procedures is necessary to determine whether these procedures have any clinical utility.