Psychosocial Treatments

Although this chapter has presented only pharmacotherapies for opioid addiction, it is crucial that psychosocial interventions be used to help these patients change their lifestyles. It is generally accepted that escape from drug seeking and the accompanying antisocial impulses requires a change in deeply rooted behavioral patterns. Individual and group psychotherapy may be useful in approaching this goal. Contingency management may be very helpful (Robles, Stitzer, Strain, Bigelow, &...

History

Marijuana has been used since antiquity, and it can be found in numerous ancient texts. The oldest known reference to marijuana is in a 15th-century B.C. Chinese text on herbal remedy (Walton, 1938). Also, Assyrian cuneiform tablets from 650 B.C. that contain references to people smoking marijuana are generally regarded as obvious copies of much older texts, according to Walton. Although archeological findings in Berlin, Germany, suggest that marijuana was in Western Europe by 500 B.C., an...

Trends In Treatment And Prevention

From the time of Benjamin Rush, two central treatment methods were established, based on the psychiatric treatment methods of the late 1700s (1) asylum in a supportive environment away from drink and companion drinkers and (2) moral treatment, consisting of a civil, respectful consideration for the recovering person (Johnson & Westermeyer, 2000). Both methods persist today and remain as two standard treatment strategies. They were not and are not inevitably successful. Consequently, other...

The Neurobiology of Substance Dependence

GEORGE HERBERT D. KLEBER Tolerance, dependence, and addiction are all manifestations of brain changes resulting from chronic substance abuse and involve different brain pathways than those subserving acute drug reinforcement. Acute drug reinforcement appears to share a final common dopaminergic pathway from the ventral tegmental area of the brain to the nucleus accumbens. These acute processes are relatively unimportant for pharmacotherapy of dependence and addiction...

Cognitive Behavioral and Nonpharmacological Treatments

Cocaine disorders have proven to be refractory to both psychological and pharmacological treatment. Consequently, considerable energy has been directed toward developing and testing the efficacy of new psychotherapeutic approaches in the treatment of cocaine use disorders. Many of these therapies have been adapted from ones originally developed to treat alcoholism. One approach that has received attention is cognitive-behavioral relapse prevention (Marlatt & Gordon, 1985). Relapse prevention...

Emotion

The intensity of emotional experience and appropriate expression of emotion are strongly associated with the quality of psychological adjustment. Conflicts over anger and guilt, and the display of intense emotional reactions commonly accompany substance use. These disruptive emotions may either presage substance use or emerge following drug use onset. Not uncommonly, consumption of psychoactive substances is motivated by a need to ameliorate negative affective states such as anger, depression,...

Cardiovascular System

It is well established that alcoholic heart muscle disease is a complication of long-term alcoholism and not malnutrition or other possible causes of dilated cardiomyopathy. In a dose-dependent fashion, left ventricular systolic function declines, implicating alcohol in at least 30 of all dilated cardiomyopathies (Lee & Regan, 2002). The contractility of heart muscle is decreased through alcohol's effect of increased calcium flow into muscle cells, decreased protein synthesis (possibly...

Endocrine System

Alcohol interferes with gonadal function even in the absence of cirrhosis by inhibiting normal testicular, pituitary, and hypothalamic function. Testicular atrophy, low testosterone levels, decreased beard growth, diminished sperm count, and a loss of libido result. However, testicular atrophy does not occur in all male alcoholics but is associated with alcohol dehydrogenase polymorphism in the testes, as reflected by the genetic variant of an increased frequency of the ADH21 allele (Yanauchi...

Pharmacological Interventions And Treatment Implications

In summary, the various biological models of drug addiction are complementary and broadly applicable to chemical addictions. We next illustrate how long-term pharmacotherapies for opioid dependence, such as methadone, nal-trexone, and buprenorphine, can counteract or reverse the abnormalities underlying dependence and addiction. These agents are particularly informative, because they are an agonist, antagonist, and partial agonist, respectively. We do not review short-term treatments for...

Contributors

Acosta, PhD, Department of Psychiatry, St. Luke's-Roosevelt Hospital Center, New York, New York D. Andrew Baron, PhD, Department of Psychiatry and Behavioral Medicine, Temple University, Philadelphia, Pennsylvania David A. Baron, DO, MSEd, Department of Psychiatry and Behavioral Medicine, Temple University, Philadelphia, Pennsylvania Steven H. Baron, PhD, Department of Social Sciences, Montgomery County Community College, Blue Bell, Pennsylvania Judith S. Beck, PhD, Beck Institute...

Psychological Processes Integral To Substance Abuse

Cognitive processes encompass both cognitive style and cognitive capacity. Both aspects are relevant to understanding substance abuse. Cognitive style refers to the general strategy an individual uses to process information. For example, substantial evidence indicates that substance abusers are more inclined than the general population to analyze perceptual stimuli in a global, inarticulate manner (Sugerman & Schneider, 1976). This stable trait is referred to as perceptual field dependence....

Discontinuation of Benzodiazepine

Discontinuation of sedatives and hypnotics, including the benzodiazepines, can be divided into three categories (1) long-term low-dose benzodiazepine use, (2) high-dose benzodiazepine abuse and multiple drug abuse, and (3) high-dose abuse of nonbenzodiazepine sedatives and hypnotics (especially intermediate-acting barbiturates). The first group of patients can usually be discontinued on an outpatient basis. Some of the second and even the third group can be treated as outpatients, but most will...

Preparation And Routes Of Administration

Cocaine is the most potent stimulant of natural origin. It is a benzoyl-methylecgonine, an ester of benzoic acid and a nitrogen-containing base. Cocaine occurs naturally in the leaves of Erythroxylon coca and other species of Erythroxylon indigenous to Peru, Bolivia, Java, and Columbia. There are several basic routes to cocaine administration chewing the leaves, cocaine sulfate (paste), cocaine hydrochloride, freebase cocaine, and crack cocaine. South American natives who chew coca leaves...

Psychiatric Disturbance

Substance abuse can occur conjointly with virtually any Axis I or Axis II psychiatric disorder. This has important treatment implications, the most obvious of which is that for some individuals, alcohol or drug consumption may constitute an attempt at self-medication. Hence, treatment of the primary disorder may in some circumstances be sufficient to ameliorate the substance use disorder. Alternatively, prolonged drug abuse may precipitate a psychiatric disturbance, either directly by inducing...

Treatment Considerations

At its simplest, treatment of patients with chronic multiple SUDs requires a focus upon each disorder separately, in addition to providing patients with a coherent overall rationale and approach to addiction treatment. Although multiple SUDs have a net negative impact on treatment outcome, Abellanas and McLellan (1993) have shown that patients with multiple SUDs report generally similar motivation for change across drugs of abuse, meaning that their desire to modify their substance use remains...

Drug Abuse Dependence

A common comorbidity associated with alcohol use disorders is co-occurring drug use disorders. In 2001, the National Household Survey on Drug Abuse found that among teenagers who binge drink, two-thirds were also abusing drugs. In contrast, one in 20 teenagers who did not drink abused drugs. Drawing upon the ECA and NCS data, it has been determined that one in five individuals with an alcohol use disorder will also have a drug use disorder. A breakdown of the NCS data indicates that those with...

Treatment

Given the high rates of placebo response often observed in treatment trials of PG, the treatment section focuses on findings from double-blind, placebo-controlled trials (see Table 13.2). SRIs are the most well-studied pharmacotherapy for PG. In a double-blind study with one subject, 125 mg day of clomipramine resulted in significant improvement. The patient sustained improvement for 28 weeks on a dose of 175 mg day (Grant, Kim, & Potenza, 2003). Fluvoxamine has demonstrated mixed results in...

Drug Tolerance Dependence And Withdrawal

From a clinical standpoint, withdrawal can be one of the most powerful factors driving dependence and addictive behaviors. This seems particularly true for opioids, alcohol, benzodiazepines, nicotine, and to a lesser extent stimulants such as cocaine. For hallucinogens, cannabinoids, or inhalants, withdrawal symptoms seem of more limited importance. Treatment of the patient's withdrawal symptoms is based on understanding how withdrawal is related to the brain's adjustment to these drugs after...

Withdrawal

A withdrawal syndrome, often referred to as the crash, consists of strong craving, electroencephalograph abnormalities, depression, alterations in sleep patterns, hypersomnolence, and hyperphagia Jones, 1984 . However, because abrupt discontinuation of cocaine does not cause any major physiological sequelae, cocaine is stopped and not tapered or substituted by a cross-tolerant drug during medically supervised withdrawal. Following the resolution of intoxication and acute withdrawal symptoms,...

Integration Of Psychotherapy And Pharmacotherapy For Dually Diagnosed Patients

Integrated psychosocial treatments are increasingly accepted and provided to patients as more and varied evidence accrues regarding their benefits. However, there continue to be few trials that integrate novel psychosocial treatments with novel pharmacotherapies. Instead, most treatments either focus on new pharmacological or new psychosocial interventions. Despite this, more recent research has emphasized the importance of integrating pharmacological and psychotherapeutic treatment options. In...

Testing Methodologies

A multitude of methods are available to aid in the detection of drug use in humans. The most common drug testing technologies are listed in Table 4.1. The most popular initial test screen is an enzyme immunoassay EIA analysis of a urine sample. If this is positive, a confirmatory gas chromatography-mass spectroscopy GC-MS test is performed on the split sample. Given the greater sensitivity of GC-MS over EIA, the cutoff levels are reduced. The most commonly used analytic technique for a...

Linking Assessment And Treatment The Decisiontree Procedure

A three-stage evaluation procedure provides a systematic framework for connecting assessment and treatment. The first stage involves brief screening using the DUSI-R Tarter, 1990 . At this stage, the areas of disturbance that point to the need for comprehensive evaluation are identified. In the second stage, a diagnostic evaluation is performed in the identified problem areas. This information in turn is applied to a focused, in-depth evaluation to formulate a multi-disciplinary treatment plan....