Building on the findings related to neurobiological influences in addiction and the importance of managing relapse, investigators have developed several pharmacological interventions to manage the symptoms of intoxication and withdrawal, as well as to control cravings. For example, the introduction of naloxone(Drug information on naloxone), an opioid antagonist, as an emergency intervention for narcotic overdose has saved countless lives.30
The next major advance occurred when clonidine(Drug information on clonidine) (an a2-adrenergic agonist) was identified as a nonopiate treatment to reverse the effects of opiate withdrawal.31 Building on this finding, treatment with naltrexone(Drug information on naltrexone) (a pure opioid antagonist) following clonidine therapy was introduced to assist with rapid drug detoxification and to offer an alternative to methadone(Drug information on methadone) maintenance therapy.32 Methadone maintenance therapy and buprenorphine(Drug information on buprenorphine) therapy continue to assist individuals in managing symptoms of withdrawal to overcome opiate addiction; however, the advances in detoxification methods allow individuals the opportunity to live drug free.
More recently, injectable naltrexone has been approved to help individuals who struggle with adherence to daily treatment. In addition, acamprosate(Drug information on acamprosate) (a GABA agonist/glutamate antagonist) has been shown to be efficacious in reducing alcohol(Drug information on alcohol) consumption in persons with alcohol dependence, without adverse effects.33 However, in a recent study, naltrexone and/or behavioral therapy were found to be more efficacious than treatment with acamprosate or placebo.34 Varenicline(Drug information on varenicline), a partial nicotine(Drug information on nicotine) agonist, has been approved to treat nicotine dependence by combating withdrawal symptoms and blocking the effects of nicotine. Unfortunately, no pharmacological treatments for cocaine yet exist, and prevention remains the best treatment.
Many persons with substance abuse actually choose to change their behavior on their own.35 However, for those who are not ready to change, motivational interviewing approaches may help.36 Motivational interviewing is a brief, patient-centered, directive approach that emphasizes personal choice and responsibility. It has demonstrated efficacy with addiction populations related to both quitting/cutting down on substance use or accepting formal treatment. In addition, research has shown that contingency management techniques, most notably voucher-based reinforcement therapy, can help patients achieve abstinence from various substances of abuse including cocaine and other stimulants, opioids, marijuana, tobacco, and alcohol.37 Voucher-based reinforcement therapy has also shown efficacy in promoting adherence to pharmacotherapy, psycho- therapy, and other support services
Cognitive-behavioral therapy (CBT) is a relatively brief treatment approach that often serves as the foundation of psychosocial intervention for patients with addictions. CBT typically combines psychoeducation, functional analysis, skill-building, environmental modification and contingency management, examination of dysfunctional thinking, coping skills training, and other techniques. The therapist will teach and encourage more adaptive thinking, work with the patient to address barriers to sobriety, teach alternative coping strategies, and assist the patient to identify and elicit social support. Marital and/or family therapy may also be used to augment other interventions in order to decrease environmental conflict and improve support, because this is generally associated with greater success in maintaining recovery.38
Participation in a 12-step program (eg, Alcoholics or Narcotics Anonymous, Double Trouble in Recovery) is beneficial for many individuals with an addiction disorder.39 Although some individuals are hesitant to join these groups, psychiatrists can assist these patients through "12-step facilitation."40 This approach involves providing psychoeducation and focusing on 3 core topics:
- Introducing the patient to the 12-step philosophy.
- Working with the patient to complete the first 3 steps.
- Encouraging the patient to become actively involved in a 12-step program.
Alcoholics Anonymous is currently the most popular mutual-help group for Americans with alcohol addiction, but even those with dual diagnosis benefit from participation in a 12-step program.41 Indeed, participation in a 12-step program is associated with increased self-efficacy for abstinence and spirituality.42 Participants who help others show lower rates of relapse, and most participants in the later stages of recovery continue to help other addicts.42,43
Research and clinical experience also demonstrate the utility of random drug testing as both a preventive tool and a component of treatment for patients with chemical addictions. Although many clinicians rely on self-reports or collateral reports, because of improved accuracy, urine screening is generally viewed as the preferred method for assessing substance use.44 It is also more sensitive and less invasive than blood testing, and it can be augmented by hair testing (for some drugs) to assess for drug use over long periods. Negative findings on drug testing are a common outcome measure in addiction research and an essential component of recovery according to the Betty Ford Institute Consensus Panel.45 When alcohol is the drug of abuse, urine screening for ethyl glucuronide may provide a more sensitive assessment than blood or breath tests.46 Drug testing does not provide information regarding levels of impairment or presence of an addiction; rather, results indicate whether the drug was recently used by the individual.