Management of addiction

Approaches to management:
 The treatment goal depends on the diagnosis.
• In general, if the diagnosis is hazardous or harmful
drinking, the goal of treatment is controlled drinking.
• If the diagnosis is alcohol dependence, or
dependence on other drugs, the recommended goal of
treatment is abstinence.
• However, this is not always feasible or acceptable to
the patient initially.
The treatment of alcohol and substance use disorders is based
on :
• An understanding of the individual’s freedom to exercise personal
responsibility
• choice in relation to his/her alcohol or substance use.

In negotiating a management plan, it is important to understand:

• what the patient is seeking .
•what his/her motivation is.
goal may involve :
•enhancing his/her motivation to change .
•attempting to move the patient towards an acceptable negotiated goal.
Treatment of alcohol dependence or other drug
dependence
 The 10-step approach to management of dependence
1. Information/education:
Provide education, information, and advice regarding
• the nature of dependence.
• feedback and education (where needed) on the medical, psychiatric,
and social complications of substance use that the individual has already
experienced or risks experiencing.
• Explain that dependence is a chronic relapsing disorder and that if they
resume drinking or taking substances they are likely to rapidly return to
their previous levels of use.
2. Recognition and acceptance:
The dependent patient must then reach a point of acceptance of the need
to stop and develop a commitment to stop drinking or using substances.

3. Detoxification:
 A necessary first step. This allows the patient to cease
alcohol or substance use in a comfortable and non-distressing
manner.
 It may involve symptomatic management of withdrawal
symptoms.
 Detoxification may be medicated or non-medicated depending
on the severity of withdrawal.
 It can be conducted on an ambulatory or in-patient basis.
Ambulatory detoxification requires :
• The patient’s commitment
• Close liaison between the medical officer, general practitioner,
and psychologist/ counsellor.
In-patient detoxicfication:
• Ambulatory detoxification may not be feasible if there is
an unsuitable home environment .
• Also, individuals who are dependent on more than one
drug (e.g. benzodiazepine plus alcohol), or who have
significant medical or psychiatric co-morbidity.
4. Pharmacotherapy:
To suppress the internal driving force of dependence.
Pharmacotherapies used to treat substance dependence:

• Smoking :
• - Substitution therapy:
• - Nicotine replacement (patches, gum)
• - Nicotinic partial agonists—Varenicline
• - Anti-craving agents
• - Bupropion
• - Varenicline.
• Alcohol dependence :
• - Anti craving agents
• - Acamprosate
• - Naltrexone
• - Nalmefene
• - Alcohol sensitizing drugs:
• - Disulfiram.
• Opioid dependence
• - Substitution therapy:
• - Methadone
• - Buprenorphine - Suboxone ®
• - Opioid antagonists:
• - Naltrexone.
5.Psychological treatments:
This very important component of treatment includes:
• Brief advice : Simple medical advice may be used to help
engage the patient with ongoing treatment.
• Counselling: this may provide general support, but increasingly
also employs specific psychotherapies.
• Motivational enhancement therapy : Building an
effective therapeutic relationship is an important component
in motivating the patient to reduce or give up alcohol or drug
use.
 The change cycle :
Prochaska & DiClemente (1986) developed a model for
assessing the patient’s ‘stage of change’ in relation to their
substance use. This involves progression through five stages:
Individuals typically recycle through
these stages several times before
termination of the addiction.
Relapse: Both the clinician and the patient need to understand
that relapse is part of the change cycle. Even after patients have
found an alternative solution to drugs or alcohol they may have
trouble remembering to use it.
Altering an automatic behaviour is difficult. Help your patients
to see that failure is only the point at which we stop trying. If
we are still trying, we haven't failed.
We can learn from our set-backs and ultimately succeed.
6.Treatment of co-morbidity and complications of
alcohol and other substance dependence:
• Medical complications or co-morbidity.
• Psychiatric co-morbidity or complications .
 Schizophrenia and Nicotine.
 Depression: If there is significant depression, this may lead to
relapse to benzodiazepine use. It is advisable to stabilize
on an antidepressant before attempting to stop the
benzodiazepine.
 Pre-existing anxiety disorders will need treatment and
stabilization to facilitate benzodiazepine withdrawal, e.g. with
SSRIs.
7. Support of, and from, family and friends:
• The patient is treated within the family and
social context. Families and friends of users
require support, assistance and advice on how
to support and help the user and on how to
deal with a very difficult situation.
• Mutual help groups such as Al-Anon,Nar-Anon
have been established to support families.
8. Self-help programmes/12-step fellowship:
In many countries mutual help groups such as
AA(Alcoholics Anonymous) and NA(Narcotic
Anonymous) exist to support the dependent user.
• Regular attendance at meetings with abstinence as a goal
has been found to be useful in achieving and maintaining
abstinence.
• These are based on the 12-step programme on the
principle that alcohol and substance dependence is a
physical, mental, and spiritual disease, which requires
lifelong abstinence and participation in a recovery
programme.
The History of the 12-Step Program:
• Bill Wilson wrote out the ideas that had been developing
through his experience with and vision of alcoholism. He wrote
about the positive effects experienced when people struggling
with alcoholism shared their stories with one another.
• Wilson wrote his program in what has become known as
the Big Book. As explained in historical information from the
AA site itself, the steps were developed through synthesizing
concepts from a few other teachings he had encountered,
including a six-step program espoused by an organization called
the Oxford Group.
• In their original form, the 12 Steps came from a spiritual,
Christian inspiration that sought help from a greater power as
well as from peers suffering from the same addiction struggles.
• The Big Book was originally
written as a guide for people
who couldn’t attend AA
fellowship meetings, but it soon
became a model for the program
in general. It has since been
adopted as a model for a wide
range of addiction peer-support
and self-help programs designed
to help drive behavioral change.
• In addition to the original
Alcoholics Anonymous (AA)
group, various offshoots now
exist, such as Narcotics
Anonymous (NA), Heroin
Anonymous (HA), and Gamblers
Anonymous (GA).
9.Continuing follow-up/after care (and residential
rehabilitation in some cases):

• Regular follow-up, ongoing review, re-evaluation, and re-

negotiation of treatment goals and management plans play
a very important role. In the process support is provided,
motivation boosted, and brief cognitive behavioural or other
psychotherapy may be provided.
• Close collaboration between the patient’s own GP and the
specialist Addiction Medicine team can greatly increase
integration of treatment and maximize the chance of success.
 Rehabilitation program

Inpatient program Outpatient program

(12 steps programe)

Long term Short term High intensity Low intensity

2m-6m 28days-6weeks >9-20h/ week <9h/week

(12steps)
Residential in-patient treatment and rehabilitation programmes:
• Patients with severe alcohol or/or other substance
dependence who fail to respond to multiple in-patient
detoxifications and outpatient treatment programmes, and
who repeatedly relapse are referred to a more intensive
residential treatment or rehabilitation programme which may
last weeks to months.
• Patients are most often referred to such services by specialist
drug and alcohol treatment units.
• Other criteria for referral to residential
in-patient treatment programmes include:
- Lack of ability to adhere to treatment
- Homelessness and lack of social support
- Severe life crises
- Concurrent medical or psychiatric illnesses.
 Common addiction treatment aproaches:
1. Cognetive behavioural therapy.(CBT)
helps users understand how their thoughts and influence their
behaviors.
They learn how to replace negative thoughts that can lead to self
destructive behaviors with positive ones that promote healthier
behaviors.
2. motivational interviewing, which makes the most of people's
readiness to change their behavior and enter treatment
3.motivational incentives (contingency management): which
uses positive reinforcement to encourage abstinence from drugs.
(e.g., failing a drug test or not taking prescribed medications)
4.Matrix Model of Addiction Treatment:
• The Matrix Model is a treatment approach that is administered
over the course of a structured, 16-week period.
• Used most often with people who are addicted to stimulants
(mainly cocaine and methamphetamine).
• it can be implemented in the treatment of any type of
substance use disorder and has even been adapted for
residential inpatient settings.
• In most MM programs, participants come to the rehab center
for treatment and return home each day.
• In contrast to alcoholics, people who are addicted to cocaine
and other stimulants tend to have shorter histories of use,
experience periods of abstinence followed by relapse, and are
not in denial about their addictions. They have powerful
cravings, and preventing relapse is the key issue in treatment.
 The main components of the model are:
1. Individual therapy sessions: These meetings focus on treatment
planning and checking in to determine the person’s progress in the
program. They may also involve family members or significant others.
2. Early recovery groups: Users who are in the first months of sobriety
meet to learn tools for dealing with cravings and managing their
time. They create a daily schedule and monitor their progress with
support from other group members.
3. Relapse prevention groups: Users learn and share strategies for
staying sober. These groups are very organized and include 32
different topics on preventing relapse, such as changing behaviors,
altering patterns of thinking, and getting involved in 12-step groups.
4. Family education groups: These groups take place over the course
of 12 weeks and teach family members about the biology of
addiction, the health effects of drugs, the conditioning of addiction,
and effects of addiction on the family.
4.Social support groups: These groups occur in the last month of
treatment. Users focus on finding drug-free activities and friends that
do not use.
5.Twelve-step meetings: Part of the Matrix Model approach is
introducing participants to the 12 steps and encouraging them to
attend meetings. Some programs have onsite meetings.
 the model incorprates several therapies: such as:
• Cognitive behavioral therapy.
• Motivational interviewing.
• Contingency management.
 Matrix Model programs also perform drug tests randomly on
a weekly basis. Drug testing is used to keep users accountable
and reward sobriety. It is not used to punish users. A positive
drug test may indicate a need for increased structure in the
program.
 Treatment consists mainly of groups, with 3 to 10
individual sessions over the duration of the program.
 Patients attend 2 relapse prevention groups and 1
family/education group per week.
 During the first 4 weeks, they also attend 2 early
recovery skills groups per week.
 After they’ve been in the program for 12 weeks, they
attend the social support group instead of the family
education group.
 10.Life style and environmental change:
 Changes at work, home and environment to deal with
antecedent or perpetuating factors may be necessary, e.g. if the
patient lives with family or friends who are heavy drinkers or
substance users, moving house may be a key to success.
 Many individuals who use illicit drugs find that the only way they can
avoid drug use is to limit or eliminate contact with using friends.
 Adopting a healthy life style with regular healthy meals and exercise
are important in restoring health.
 Some patients with severe and complicated alcohol and substance
use disorders are unwilling or unable to cease use. Most patients will
not be able to totally avoid slip ups or relapses when they engage
with treatment, even though they may be striving to cease their
substance use
Pharmacological treatment
 Alcohol dependence
clinical assessment :
■ history of alcohol use, including daily consumption and recent
patterns of drinking .
■history of previous episodes of alcohol withdrawal.
■ time of the most recent drink.
■ collateral history from a family member.
■ other drug (illicit and prescribed) use.
■ severity of dependence and of withdrawal symptoms .
■ coexisting medical and psychiatric problems.
■ physical examination, including cognitive function.
■ breathalyser: absolute breath alcohol level and whether rising
or falling (take at least 20 minutes after last drink to avoid
falsely high readings from the mouth, and 1 hour later).
• laboratory investigations:
• full blood count
• urea and electrolytes (U&E).
• liver function tests (LFTs).
• international normalised ratio (INR).
• prothrombin time (PT).
• urinary drug screen.
• The Alcohol Use Disorders Identification Test (AUDIT) questionnaire is a
10-item questionnaire which is useful as a screening tool in those identified
as being at increasing risk.
 Questions 1–3 address the quantity of alcohol consumed, 4–6 the signs and
symptoms of dependence and 7–10 the behaviours and symptoms
associated with harmful alcohol use.
 Each question is scored 0–4, giving a maximum total score of 40. A score of
8 or more is suggestive of hazardous or harmful alcohol use. Hazardous
drinking = consumption of alcohol likely to cause harm. Harmful
drinking = consumption already causing mental or physical health problems.
• The Severity of Alcohol Dependence Questionnaire (SADQ)5:is a more
detailed 20-item questionnaire with the score on each item ranging from 0
to 3, giving a maximum total score of 60.
Alcohol withdrawal:
In alcohol-dependent drinkers, the central nervous system has
adjusted to the constant presence of alcohol in the body
(neuro-adaptation). When the blood alcohol concentration
(BAC) is suddenly lowered, the brain remains in a hyper-excited
state, resulting in the withdrawal syndrome.
Pharmacologically assisted withdrawal (alcohol
detoxification)
Alcohol withdrawal is associated with significant morbidity
and mortality when improperly managed.
Pharmacologically assisted withdrawal is likely to be needed
when:
■ regular consumption of >15 units/day
■ AUDIT score >20
■ there is a history of significant withdrawal symptoms.
Community detoxification is usually possible when:
■ There is a supervising carer, ideally 24 hours a day throughout the
duration of detoxification process.
■ The treatment plan has been agreed with the patient, their carer
and their general practitioners (GP).
■ A contingency plan has been agreed with the patient, their carer
and their GP.
■ The patient is able to pick up medication daily and be reviewed by
professionals regularly throughout the process.
■ Outpatient/community-based programmes including psychosocial
support are available.
Community detoxification should be stopped if the patient resumes
drinking or fails to engage with the agreed treatment plan.
 Inpatient detoxification is likely to be required if:

• Regular consumption is >30 units/day.

• SADQ >30 (severe dependence).
• There is a history of seizures or delirium tremens.
• The patient is very young or old.
• There is current benzodiazepine use in combination with alcohol.
• Substances other than alcohol are also being misused/abused.
• There is co-morbid mental or physical illness, learning disability
or cognitive impairment.
• The patient is pregnant.
• The patient is homeless or has no social support.
• There is a history of failed community detoxification
• Benzodiazepines
• the treatment of choice for alcohol withdrawal. They
exhibit cross-tolerance with alcohol and have
anticonvulsant properties.
• In the UK, chlordiazepoxide is the benzodiazepine used
for most patients in most centres as it is considered to
have a relatively low dependence-forming potential.
• Some centres use diazepam.
• A short-acting benzodiazepine such as oxazepam or
lorazepam may be used in individuals with impaired liver
function.
• Parenteral thiamine (vitamin B1), is an important
adjunctive treatment for the prophylaxis and/or
treatment of Wernicke–Korsakoff syndrome and other
 Fixed-dose reduction regimen
• Moderate alcohol dependence: example of a
fixed-dose chlordiazepoxide treatment
regimen.
• Day 1 20mg qds 80
• Day 2 15mg qds 60
• Day 3 10mg qds 40
• Day 4 5mg qds 20
• Day 5 5mg bd 10
Treatment of somatic symptoms:
 Relapse prevention:
 There is no place for the continued use of
benzodiazepines beyond treatment of the acute alcohol
withdrawal syndrome.
 Acamprosate and supervised disulfiram are licensed
for treatment of alcohol dependence in the UK and may
be offered in combination with psychosocial treatment.
 Naltrexone is a non-selective opioid receptor antagonist,
significantly reduces relapse to heavy drinking. prevents
increased dopaminergic activity after the consumption
of alcohol, thus reducing its rewarding effects.
 50mg/day with a trial dose of 25mg for 2 days to check
for side effects.
delirium tremens
• All patients with delirium tremens should have
IV thiamine at treatment dose, as malnutrition
is a known predisposing cause of DTs.
• Sufficient sedation should be achieved to
facilitate the giving of this treatment and IV
rehydration.
 Opioid dependence
It is strongly recommended that general adult
psychiatrists do not initiate opioid substitute
treatment without obtaining advice from
specialist services.
 All opioids are respiratory depressants.
 Prescribed opioids such as methadone and
buprenorphine have low lethal doses in drug-
naïve individuals, and assessing tolerance is
difficult.
 Opioid toxicity can be fatal. Opioid withdrawal
is not.
Treatment of opioid overdose:
• Opioid overdose is characterised clinically by:
■ unconsciousness
■ a low respiratory rate (RR < 12)
■ pinpoint pupils
■ cyanosis
■ cold, clammy skin.
Naloxone is an opioid receptor antagonist that can reverse opioid overdose.
An initial dose of 400μg is recommended, which can be repeated following three
cycles of 30 chest compressions
until the ambulance arrives or breathing resumes. Higher doses of naloxone may be
necessary to displace opioids of high affinity such as buprenorphine or fentanyl
Intranasal
The peak plasma concentration (Cmax) of 1mg, 2mg and 4mg IN naloxone exceeds
that of 400 μg IM naloxone but time to attainment of peak concentrations (Tmax)
is delayed relative to IM administration (15–30 minutes vs 10 minutes). With
respect to time to onset of action, 2mg IN is equivalent to 400 μg IM. IN
administration results in more persistent naloxone plasma levels than IM or IV
routes.
 Methadone and buprenorphine are the Opioid substitution
treatment (OST) medications recommended by NICE(National
Institute for Health&Care E xcellent) for maintenance substitute
prescribing.
 Both methadone and buprenorphine maintenance are effective
in treating withdrawal symptoms and decreasing use of illicit
opioids.
 Recent guidelines and systematic reviews find that there is no
evidence to support one over the other.
 Methadone is a full agonist at µ-opioid receptors while
buprenorphine is a partial agonist.
Methadone cautions:
 Intoxication.
 Severe hepatic/renal dysfunction.
Sublingual buprenorphine:
 It alleviates/prevents opioid withdrawal and craving.
 It reduces the effects of additional opioid use because of its
high receptor affinity – what patients refer to as a ‘blocking’
effect.
 It is long-acting allowing daily (or less frequent) dosing.
Prolonged-release buprenorphine injection: trade
name‘Buvidal’
Buprenorphine with naloxone (Suboxone):
Consideration may be given by the prescriber to
buprenorphine/ naloxone prepara-tion which may reduce
the risk of diversion.
Nicotine and smoking cessation
Nicotine replacement therapy (NRT)
 Combination NRT (i.e. combining two formulations such as a patch and
an oral/nasal product) is more effective than using a single NRT product.
Varenicline:
 Varenicline is a selective nicotinic acetylcholine receptor
partial agonist. It mimics the action of nicotine and causes a
sustained release of dopamine in the mesolimbic pathway.
 It also blocks dopamine release resulting from subsequent
nicotine intake. This means if taken as prescribed, any
attempt to smoke a cigarette will be less pharmacologically
rewarding and feel less satisfying to a smoker.
Bupropion:
 Bupropion is an antidepressant with dopaminergic and
adrenergic actions and is additionally an antagonist at the
nicotinic acetylcholine receptor.
 contraindicated in those with seizure disorders, eating
disorders and alcohol dependence.
Electronic cigarettes and vaping:
 In the most recent Cochrane review of the effect of e-
cigarettes for smoking cessation, quit rates were
significantly higher for people who used e-cigarettes
containing nicotine compared with those who either
used an e-cigarette without nicotine or NRT.
 Nicotine content ranges from zero (0%) to a maximum
of 20mg/mL (or 2%). Nicotine salts (as an alternative to
e-liquid) have recently become popular with e-cigarette
users; salts have a lower pH level, enabling a smoother
throat-hit and for some users, purportedly providing a
sensation that is more similar to smoking. Additionally,
nicotine salts allow vaporisation at a lower temperature
and enable higher nicotine levels to be inhaled, which
may help with switching from smoking to vaping.
 Pharmacological treatment of dependence on
stimulants
Cocaine:
Detoxification:
 Symptoms of withdrawal include depressed mood, agitation and insomnia.
 These are usually self-limiting. It should be noted that given cocaine’s short
half-life and the binge nature of cocaine use, many patients essentially
detoxify themselves regularly with no pharmacological therapy.
 Symptomatic relief such as the short-term use of hypnotics may be helpful
in some, but these agents may become agents of dependence themselves
for some patients.
Substitution treatment:
There is little evidence for substitution therapy for the treatment of
cocaine misuse and it should not usually be prescribed
• Amfetamines
A wide variety of amfetamines are misused, including
‘street’ amfetamine, methamphetamine and
pharmaceutical dexamfetamine. Any drug in this class is
likely to have misuse potential.
• Detoxification
• A withdrawal syndrome is common in those who are
dependent. Treatment should focus on symptomatic
relief, although many symptoms of amfetamine
withdrawal (low mood, listlessness, fatigue, etc.) are
short-lived and may not be amenable to
pharmacological treatment.
• Insomnia can be treated with short courses of
hypnotics
 Benzodiazepine misuse
 benzodiazepines have a high potential for causing dependence.
 common in older patients and those with anxiety spectrum
disorders or depression(iatrogenic)
 People with non-iatrogenic benzodiazepine dependence often
consume doses greater than 100mg diazepam a day.
 A more recent review confirmed that withdrawal over a period
of less than 6 months is appropriate for most patients and the UK
drug misuse
 Dependence guidelines suggest a reduction of about one-eighth
of the daily dose every 2 weeks.
 Discontinuation should usually be completed within 6 months.
 switching to an equivalent dose of diazepam before withdrawal is
commonplace.
 Benzodiazepine misuse is frequently seen in multi-substance
misuse where opioids may be the primary drug of dependence.
Synthetic cannabinoid receptor agonists (SCRAs)
• The clinical importance of SCRAs relates to their acute toxicity
(which is potentially life-threatening), their relationship to
psychosis and their propensity to induce dependence.
• SCRAs are a structurally diverse group of chemicals that act as
an agonist at the CB1 receptor.
• SCRAs are more potent in their action at the CB1 receptor and
can be longer lasting than tetrahydracannabinol (THC), the
main psychoactive ingredient in cannabis.
Features of acute SCRA intoxication:
Management of acute SCRA intoxication:
• Patients should be cared for in an appropriate setting
• ECG cardiac monitoring to detect ischaemia and
arrhythmias
• Blood tests – blood gas, U&Es, creatine kinase and LFTs
• Supportive treatment with benzodiazepines
• IV fluids, supplemental oxygen and anti-emetics
• Rarely antipsychotics or anaesthesia.
• Reassuringly, neither antipsychotic nor benzodiazepine
use in SCRA intoxication has
• been associated with adverse cardiovascular effects and
antipsychotics have not been
• associated with increased incidence of seizures.
Management of SCRA-related psychosis:
• has more prominent positive symptoms than cannabis-
related psychosis has less prominent negative symptoms
than cannabis-related psychosis.
• is less likely to have manic features.
• is commonly associated with suicidal thinking.
• psychiatric admission may be necessary to manage
behavioural disturbance.
• requires higher doses of antipsychotic than cannabis-
related psychosis (mean dose equivalent to 11mg
haloperidol, whereas in cannabis users mean dose was
6mg/day and those without either co-morbidity 3mg/day) .
• requires longer treatment than cannabis-related psychosis.
Management of SCRA dependence and withdrawal:
 Patients with months of daily use experience a physiological
withdrawal syndrome lasting several days, including the following:
■ Disturbed sleep
■ Strange dreams
■ Restlessness
■ Anxiety
■ Craving
■ Shivering
■ Muscle twitching
■ Increased heart rate and blood pressure
 Treatment with benzodiazepines has been reported both to be
effective and ineffective.
 Low-dose quetiapine (50mg) was effective in the case of
benzodiazepine failure.