Treatment Ch18

© 2009 McGraw-Hill Higher Education. All rights reserved.

Chapter 18

Treating Substance Abuse and Dependence


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


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



§ 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

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

eliminating heroin use

§  Tobacco § Complete abstinence (most common goal) vs. cutting

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



§  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


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

but not the responsibility for dealing with it

§ Major approaches are group support and a buddy system


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


Motivational Enhancement Therapy

§  Conventional wisdom about people with substance abuse problems: § Most substance abusers use the

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

§  Problem with this perspective is that very serious consequences may occur before the abuser is ready for treatment



§ 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



§  Stages of change § Precontemplation: Individual doesn’t recognize

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



§ 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


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


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

demands on patients


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


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


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


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


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


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



§ Maintenance therapy § Usually given for weeks or months rather

than indefinitely § Three approved medications

§ Disulfiram (Antabuse) § Naltrexone § Acamprosate



§  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

§  Naltrexone §  Reduces alcohol craving, days per week of drinking, and rate of

relapse—but 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 §  Acamprosate, a compound structurally similar to GABA

§  Normalizes basal GABA concentrations §  Blocks the glutamate increases observed during alcohol withdrawal §  Recently approved, so effectiveness hasn’t been determined


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


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

determined § May inhibit reuptake of dopamine and norepinephrine and,

to a lesser extent, block acetylcholine receptors

§ Has been shown to gradually decrease cigarette craving and use


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



§  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



§  Naloxone, a short-acting opioid antagonist, is used to treat opioid overdose

§  Naltrexone, a long-acting opioid antagonist, is approved for treating opioid dependence § Has been shown to be effective, but it is appropriate

only for highly motivated individuals § A once-per-month form is being studied; initial

findings are promising


Pharmacotherapies for Cocaine

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

emotional response), fatigue, irritability, sleep and activity disturbances, craving for cocaine

§  Risk of relapse may be greatest during withdrawal period §  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


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 § One drug has been found effective: oral ∆9-THC

§  Currently no approved pharmacotherapy for cannabis dependence


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


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


Is Treatment Effective?

§  Substance dependence is a chronic illness §  Treatment doesn’t work for every

individual every time § Condition may require continuing

care throughout life §  Studies show that treatment is

cost-effective by reducing crime and increasing employment

§  Treatment also saves lives in the long term

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Treatment Ch18

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