Chapter 18

Treating Substance Abuse and Dependence

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Treatment
!! !!
Hundreds of thousands of Americans undergo treatment for substance abuse and dependence each year A variety of treatment approaches are used, often in combination !! Behavioral/psychosocial treatments !! Pharmacotherapies Different approaches reflect !! Different substance abuse problems !! Different theories about substance abuse

!!

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Defining Treatment Goals

!! !!
Treatment goals are influenced by the underlying theoretical view of substance abuse Alcohol !! View that alcohol dependence is a biological
disease that someone either has or does not have

!! Only acceptable treatment goal is complete

abstinence

!!

View that alcohol dependence represents one end of a continuum of drinking

!! A possible treatment goal is controlled social

drinking

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Defining Treatment Goals

!! Opioids
!! View that opioid dependence undermines the physical
and mental health of its victims !! Only acceptable treatment goal is abstinence (traditional
view)

!! View that dependence on legal methadone is

eliminating heroin use

preferable to dependence on illegal heroin !! Goal of treatment has changed from eliminating opioid use to

!! Tobacco

!! Complete abstinence (most common goal) vs. cutting

down on smoking or switching to cigarettes lower in tar and nicotine

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Defining Treatment Goals

!! How to evaluate treatment
outcomes of reduced use as opposed to abstinence? !! Researchers are beginning to develop cost/benefit analyses

!! Cost of treatment
vs.

!! Cost savings from increased

employment and decreased crime after treatment

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Alcoholics Anonymous
!! Founded in 1935: A loose affiliation of local
groups that adhere to common methods !! Based on the disease model of dependence

!! An alcoholic is biologically different from others, so

abstinence is the only appropriate goal !! The disease takes away a person s control over his or her own drinking behavior !! It removes the blame for the problem from the alcoholic

!! Major approaches are group support and a

buddy system
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but not the responsibility for dealing with it

Alcoholics Anonymous
!! Formal evaluations of AA have not been very
positive

!! However, studying people who have court-ordered

referrals to AA might not be an appropriate evaluation method !! A more appropriate evaluation might be to determine which types of drinkers are most likely to benefit from AA s programs !! Evaluation is important because many treatment programs follow the 12-step model of AA !! Betty Ford Center, Hazelden, Phoenix House
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Motivational Enhancement Therapy

!! Conventional wisdom about people
with substance abuse problems:

!! Most substance abusers use the

!! Problem with this perspective is

defense mechanism of denial and are unwilling to admit they have a problem !! Only when a user suffers serious consequences ( hits bottom ) will he or she be ready to seek help

that very serious consequences may occur before the abuser is ready for treatment

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Motivational Enhancement Therapy

!! Motivational enhancement therapy

attempts to shift the focus away from denial and toward motivation to change !! Motivational interviewing

!! Used to boost the motivation to change of an

ambivalent or less ready substance abuser !! A nonconfrontational process of determining the abuser s current stage of change and then helping the individual move forward
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Motivational Enhancement Therapy

!! Stages of change
!! Precontemplation: Individual doesn
that a problem exists !! Contemplation: Individual recognizes there is a problem and begins to consider the possibility of changing her or his behavior !! Preparation: Individual decides to change and makes plans to change !! Action: Individual takes active steps toward change !! Maintenance: Individual engages in activities intended to maintain the change t recognize

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Motivational Enhancement Therapy

!! Goals of motivational
interviews

!! Help the client focus on

problem behaviors !! Help the client move forward to the next stage of change

!! Motivational enhancement therapy is probably

best conceptualized as preparation for other therapies rather than as a stand-alone treatment

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Contingency Management
!! An approach in which individuals receive
immediate rewards for providing drug-free urine samples

!! Value of the rewards increases with consecutive

drug-free samples

!! Clients also participate in weekly skill-building

counseling sessions !! Has produced consistent reduction in use !! Downside of approach is the cost of rewards
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Relapse Prevention
!! An approach that combines cognitive therapy
techniques with behavioral skills training !! Individuals learn to identify and change behaviors that could lead to relapse, such as associating with drug users !! Evaluation
demands on patients

!! Shown to be more effective than most therapies !! Considered challenging because it places significant

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Pharmacotherapies
!! !!
Study of dependence as a brain disease has focused research efforts on developing medications for treatment Many experts believe that pharmacotherapies alone will not cure a chronic, relapsing, behavioral disorder like substance abuse Pharmacotherapies can provide a window of opportunity for behavioral/psychosocial treatments by relieving withdrawal symptoms

!!

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Detoxification
!! Detoxification is an initial and
immediate phase of treatment !! Medications are administered to alleviate unpleasant and/or dangerous withdrawal symptoms that may appear following abrupt cessation of drug use !! Some of these medications may also be used during maintenance stage
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Maintenance !! Maintenance is a longer-term strategy

used to help a dependent individual avoid relapse !! Three general categories of pharmacotherapy for maintenance

!! Agonist or substitution therapy !! Antagonist therapy !! Punishment therapy

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Maintenance
!! Agonist or substitution therapy is used to
induce cross-tolerance to the abused drug

!! Examples: methadone for heroin dependence,

buprenorphine (subutex) for opioid dependence, nicotine replacement for tobacco dependence !! Agonists typically have safer routes of administration and/or diminished psychoactive effects compared to the original drug !! Substituting a longer-acting, pharmacologically equivalent drug allows the user to be stabilized on the agonist and then slowly tapered off it, avoiding withdrawal symptoms
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Maintenance
!! Antagonist therapy is used to prevent the user
from experiencing the reinforcing effects of the abused drug

!! Example: naltrexone, which blocks opioid effects

!! Punishment therapy is used to produce an

aversive reaction following ingestion of the abused drug

!! Example: disulfiram for alcohol dependence

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Pharmacotherapies for Alcohol

!! Detoxification phase
!! Pharmacological therapies are important
because acute alcohol withdrawal syndrome has serious effects !! Medical risks often require an inpatient medical setting for alcohol detoxification

!! Benzodiazepines are typically used

!! Reduce autonomic hyperactivity and
prevent seizures !! Best choices are those with a slow onset of action
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Pharmacotherapies for Alcohol

!! Maintenance therapy
!! Usually given for weeks or months rather
than indefinitely !! Three approved medications

!!Disulfiram (Antabuse) !!Naltrexone !!Acamprosate

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Pharmacotherapies for Alcohol

!!
Disulfiram (Antabuse) causes unpleasant symptoms (headache, vomiting, and breathing difficulties) if alcohol is consumed

!! !!

Inhibits aldehyde dehydrogenase, thereby increasing acetaldehyde Not very effective because most people don t take the medication Reduces alcohol craving, days per week of drinking, and rate of relapsebut hasn t had a large impact on overall treatment success Unclear how it works; it may block opioid receptors and the reinforcing effects of alcohol Normalizes basal GABA concentrations Blocks the glutamate increases observed during alcohol withdrawal Recently approved, so effectiveness hasn t been determined

!!

Naltrexone

!! !!

!!

Acamprosate, a compound structurally similar to GABA

!! !! !!

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Pharmacotherapies for Nicotine

!! !!
Nicotine withdrawal symptoms (anxiety, depression, insomnia, cigarette cravings) occur in most smokers who stop smoking Five nicotine replacement products are approved by the FDA

!! !! !! !! !!

Transdermal nicotine patch Nicotine gum Nicotine nasal spray Nicotine vapor inhaler Nicotine lozenge

!! !!

Smokers should stop smoking before using any of them to avoid nicotine toxicity Use of nicotine replacement products has been shown to increase quit rates in controlled clinical studies

!!

Success rates are probably lower in a real world setting

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Pharmacotherapies for Nicotine

!! Bupropion (Zyban), a non-nicotine
pharmacotherapy for smoking cessation

!! Approved by the FDA in 1997 !! Also used in the treatment of depression !! Mechanisms of action haven t been definitively
to a lesser extent, block acetylcholine receptors

determined !! May inhibit reuptake of dopamine and norepinephrine and, craving and use

!! Has been shown to gradually decrease cigarette

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Pharmacotherapies for Opioids

!!
Traditionally, anticholinergic drugs like belladonna were used to treat opioid dependence !! Goal: To produce a state of delirium for several days so that
the dependent person would avoid experiencing withdrawal

!!

More recent version is rapid opioid detoxification, in which a dependent person is anesthetized and given an opioid antagonist that causes immediate withdrawal !! Person is released after 24 hours and enters a period of

!!

counseling while continuing to take an opioid antagonist Criticisms of approach

!! Medical risks of rapid withdrawal process !! Behavioral/psychosocial aftercare is often deemphasized !! Long term outcome studies suggest that relapse is likely
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Pharmacotherapies for Opioids

!! Detoxification
!! Medications given to reduce withdrawal symptoms

(nausea, vomiting, diarrhea, aches, pain) !! Methadone, a long-acting opioid !! Buprenorphine, a partial opioid agonist with a long duration
of action

!! Maintenance

!! Methadone maintenance is the most common form

of treatment for opioid dependence !! May continue for months or years !! Less data available on more recently approved buprenorphine maintenance

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Pharmacotherapies for Opioids

!! Naloxone, a short-acting opioid antagonist, is
used to treat opioid overdose !! Naltrexone, a long-acting opioid antagonist, is approved for treating opioid dependence
only for highly motivated individuals !! A once-per-month form is being studied; initial findings are promising

!! Has been shown to be effective, but it is appropriate

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Pharmacotherapies for Cocaine

!!
Withdrawal symptoms !! Can include depression, nervousness, anhedonia (lack of

!! !! !!

!! Reduced monoamine neurotransmitter activity may underlie withdrawal symptoms Medications that increase monoamine neurotransmitter activity have been tested but have not been found useful in treating withdrawal symptoms or dependence Currently no approved pharmacotherapy for cocaine dependence

emotional response), fatigue, irritability, sleep and activity disturbances, craving for cocaine Risk of relapse may be greatest during withdrawal period

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Pharmacotherapies for Cannabis

!! Withdrawal from cannabis
!! People seeking treatment for cannabis dependence
often report withdrawal symptoms that make it more difficult to maintain abstinence !! Symptoms may include irritability, anxiety, sleep disruption, aches

!! Many medications have been tested for relief

of cannabis withdrawal symptoms cannabis dependence

!! Currently no approved pharmacotherapy for

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!! One drug has been found effective: oral !9-THC

Treatment: The Big Picture in the United States

!!
Most frequently reported drugs for substance abuse treatment admissions !! Alcohol (40 percent) !! Opioids (18 percent) !! Marijuana (16 percent) !! Cocaine (14 percent) Abusers admitted for treatment !! Average age of those admitted with marijuana as the primary
drug of abuse is 24

!! !!

Sites of treatment !! 50 percent treated as outpatients !! 13 percent treated as hospital inpatients (detoxification) !! 17 percent treated in a residential setting

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Treatment: The Big Picture in the United States

!! Substance abuse treatment development
should focus on

!! More effective interventions for commonly abused

drugs !! Alcohol !! Opioids !! Marijuana !! Cocaine !! Treatment delivery on an outpatient basis

!! Effective outpatient behavioral/psychosocial

interventions are needed to improve the overall success of treatment

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Is Treatment Effective?
!! Substance dependence is a
chronic illness

!! Treatment doesn

!! Studies show that treatment is

t work for every individual every time !! Condition may require continuing care throughout life

cost-effective by reducing crime and increasing employment !! Treatment also saves lives in the long term
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