American Academy of Addiction Psychiatry

That bit of outdated advice terrifies the family and friends of the person with an addiction who refuses treatment, because they know that “bottom” may be serious injury, overdose, or death. Although well-described methods are available for managing the person with an addiction who agrees to come into treatment with a support group of family members and/or friends, sometimes an in-office evaluation is refused out of hand.

 So how do we, as clinicians trying to help the person with an addiction who refuses to set foot in our office, render assistance?

First, the message to the concerned family and friends should be that the time to act is now-whether or not the person with addiction comes in to the office. Second, we should model for loved ones of the person with an addiction an attitude of urgency combined with an acknowledgement of the situation’s complexity, because barring an immediate threat, there is little possibility for legally coerced treatment. Those who care can push the person with an addiction towards treatment, while still maintaining an attitude of respect for his or her autonomy, life choices, and preferences.

Psychiatrists can teach the family and friends how to recognize an immediate danger and access the appropriate level of care for a threat to the life of the person with an addiction. For instance, helping loved ones understand what an opioid overdose looks like, how to use naltrexone, and when to call 911, would be the first orders of business for someone with an opioid addiction. Or, for the individual who may or may not be in withdrawal from alcohol, informing the family about the signs and symptoms of alcohol withdrawal and alcohol poisoning educates them about what a true emergency is, and what presentations may be dealt with less urgently. The bottom line, however, is that any immediate threat to the person’s life should result in a call to 911.

Once the immediate threats are delineated, family and friends should be educated about the typical course of addiction, available treatments, and the best way to convince their loved one to accept an evaluation and eventual treatment. It is usually helpful to find out how those who care about the person with an addiction think about the addiction problem, and what they have tried up to this point. Often, families will have unrealistic or simply inaccurate views about addiction, or express (understandable!) anger if the person with an addiction has lied to them. Once these matters are on the table, the clinician can support any productive strategies already in place, counter any mistaken understandings, and suggest a specific plan for advancing treatment.

Family members who have been manipulated by a person with an addiction for money or other support are often angry and resentful. But by providing the family with psychoeducation-specifically, approaches that are likely to be helpful but also protect the family from being further abused-one can reassure family members and bring them into a makeshift “treatment team.” For example, offering to drive a family member to AA, or arranging insurance for a detox stay, or simply providing a hot meal and a chance to talk are all effective in supporting a recovery-focused view, but do not endanger the giver. By contrast, handing the person with addiction cash, allowing him or her to stay in one’s home, or even paying for an expensive treatment stay can all lead to families feeling taken advantage of and needing to protect themselves.

Families sometimes believe that the best, and sometimes only, way to confront the person with addiction is via the “Intervention” model they have seen on television.

 Although based on the influential work of Vernon Johnson,

 this model is hardly the only way to address an addiction problem in the family and can be counterproductive. Rather than using the dramatic and sometimes complicated “Intervention,” family and friends can be coached to ask about the particular problems they observe and explore possible avenues for help.

Teaching a non-confrontational communication style can be a revelation for family members bound up in hardened patterns of blaming/shaming interactions with their loved one. Role-playing is often helpful in a situation like this, as families and friends often question how they should respond to specific retorts from the person with an addiction. One example:

Roger: I don’t need your help. You know I’ve been using a lot less lately, and I’m going the right direction.

Angela: I can see, that, and I’m very glad about it. But given the heroin out there that’s laced with fentanyl, I worry about you overdosing even as you’re starting to turn the corner.

Roger: Nah, I’m really careful. And anyways, you’re my sister, not the hall-monitor!

Angela: I know, I know! I won’t even bother trying to twist your arm, but I can still worry about you! And we found a treatment program that accepts your insurance and can see you this afternoon.

Angela has been coached to acknowledge the strides that Roger has made in cutting down his use, but also remains realistic about the remaining dangers of his heroin use. And, she has learned to reassure her brother that she has no ability or intention of controlling him but does have a very specific recommendation for getting help. This sort of respectful but persistent pressure for treatment will be better received than demands or directives.

The essential point for family members to understand is that they are trying to build a therapeutic alliance with the person with addiction-and this is a skill that can be taught, even to non-clinicians, and even in the heat of a deteriorating clinical situation. Family members and friends can be coached to approach the person with addiction as non-judgmentally as possible, with initial offers of a listening ear, and with particular treatment goals in mind. The attitude must be that “we are together and we’re going to get through this,” rather than “you need to stop acting like a child,” or (even worse!) “Just say NO!”

After this initial approach is discussed, family members and friends can be coached on using basic elements of the Motivational Enhancement model.

 This is the key to most successful communications between human beings. The skills of fostering empathy, waiting for their loved one’s expression of reasons to stop using, avoiding arguments, and adjusting for resistance can all be taught as the most effective means possible for convincing the person with an addiction to get help. The most challenging aspect of this interaction style is helping the family and friends manage the resistance that they see as illogical or laughably inconsequential. The clinician can often help them prepare for this common resistance by practicing a role-play like this:

Edward: Mom, I can’t go to rehab and live there. I just don’t agree with all that God-stuff they talk about in AA. It’s not me. I’m not religious.

Sally: Well, I certainly understand that, and you’re a grown-up who can decide what you believe and what you don’t.

Edward: Good. You get it. The whole thing is ridiculous and there is no way I’m going to go into that place. Those freaks can’t help me with my relationship with Lexi and the kids.

Sally: Your relationship with Lexi and the kids?

Edward: Yeah, you know. She won’t let me see them any more until I stop drinking.

Sally: Oh honey, I know you love those kids.

Sally: We have to figure out a way for you to get back into their lives.

In this role-play, Sally has been coached to avoid the bait of arguing about AA philosophy, or confronting directly Edward’s dislike for the treatment facility. Rather, she waits for Edward to give his own personal reason to stop drinking, which he quickly does: his love for his children. This should be the driving force in his desire for sobriety and can be used by Sally and the rest of the family for motivating him to enter treatment. The family can now emphasize Edward’s reasons, rather than their own, for beginning treatment and the eventual goal of sobriety.

Of course, in real-life situations, attempts to motivate the person with an addiction rarely go quickly, or smoothly. Families should be coached to focus on the eventual intended goal, with the understanding that the path will likely include setbacks and relapses. While keeping the safety of the person with an addiction in mind, families and friends can learn to accept-although not like-giving up ground in the service of remaining engaged and ready to help. For instance, a family may have to accept their child dropping out of school, or moving out of the house, or taking public assistance funds, all in the hopes of pushing the goal of treating the underlying addictive disorder.

The most painful situations occur when a family must withdraw resources from their loved one, in the form of declining to underwrite a drug-using lifestyle, and/or asking the person with addiction to leave the family home. If the family is unintentionally supporting the drug or alcohol use, these painful decisions must be made. However, barring any actual danger to those who love the person with addiction, family and friends can remain available to arrange treatment, help with applying for Medicaid, or driving to an AA meeting.

Clinicians should disabuse the family and friends of the fantasy that they can control whether their loved one enters treatment. Instead, a realistic understanding of their abilities can allow the group to function as effectively as possible, without the fantasy that they are omnipotent and can force the person with an addiction to accept treatment.

Families and friends often misperceive the range of available addiction treatments and venues. Contrary to public perception, a standard 28-day rehab is not the only, or even the best treatment available for addictive disorders. Families should learn about, and be able to promote, a wide variety of possibilities for their particular loved one, such as intensive outpatient programs, individual therapists, Medication-Assisted Treatment (MAT), and a range of peer-led support groups such as AA. It is important that all persons involved know that addiction treatment at a reasonable cost is becoming increasingly available, although it may not seem so from the glossy ads for high-end inpatient treatment centers.

Finally, families and friends should be coached to remain optimistic, persistent, and unwavering in their support for their loved one, and in their loving confrontations of the destructive alcohol or drug use. By helping the family and friends keep themselves emotionally and physically safe, while still promoting treatment, a clinician can advance the cause of treatment and an eventually solid recovery.

Dr Westreich is Clinical Associate Professor, Department of Psychiatry, NYU Langone Health, New York, NY. He is the author of A Parent’s Guide to Teen Addiction, Skyhorse Publishing, 2017.

Network Therapy for Alcohol and Drug Abuse

Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening

Intervention: How to Help Someone Who Doesn’t Want Help

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Motivational Enhancement: Helping People Change.

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Articles

"He'll just have to hit bottom." That bit of outdated advice can be terrifying. How do clinicians trying to help the person with an addiction who refuses to set foot in our office render assistance?

Coaching Families to Address Addiction

[Acknowledgment-the authors acknowledge The 

American Academy of Addiction Psychiatry 

(AAAP) for helping to bring this article to fruition. The AAAP is a professional membership organization for learning and sharing about the science of Addiction Psychiatry translating the research into clinical practice. As relentless advocates for those suffering from the devastation of substance use disorders and mental health disorders, AAAP is driven to transform lives through a commitment to using evidenced-based research to continually improve clinical approaches and outcomes for patients.]

Illicit drug use is on the rise in the US. According to the National Survey on Drug Use and Health, 27 million people aged 12 years or older were illicit drug users in 2014-an increase from the 2002 to 2013 numbers. Results also indicate that 1.5 million people aged 12 years or older who were current users of cocaine (in all forms) included about 354,000 users of crack cocaine.

[[{"type":"media","view_mode":"media_crop","fid":"48873","attributes":{"alt":"Â© marcos mesa mam Wordley/shutterstock.com","class":"media-image media-image-right","id":"media_crop_8280155473152","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5864","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"168","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Â© marcos mesa mam Wordley/shutterstock","typeof":"foaf:Image"}}]]According to the National Institute on Drug Abuse, the national cost of illicit drug use is $11 billion in health care and $193 billion overall (including costs related to crime and lost productivity).

 Improving treatments for illicit drug use may have a widespread effect on the affected individual, on his or her family, and on society as a whole.

There are no FDA-approved pharmacotherapies for cocaine use disorder. In this article we review the off-label use of promising medications for cocaine use disorder (

). These treatments can be divided into 3 categories: dopaminergic agents, noradrenergic agents, and those with mixed mechanisms of action. Among these treatment targets are proteins with relatively frequent genetic variants that appear to mediate enhanced responses to specific pharmacotherapies. These proteins include metabolic enzymes, receptors, and receptor transducers that mediate the coupling of receptors to second messenger systems such as cyclic adenosine monophosphate.

We will focus specifically on dopamine Î²-hydroxylase (DÎ²H), dopamine receptor, ankyrin repeat and kinase domain-containing 1 (ANKK1), and Î±

Dopaminergic agents include levodopa-carbidopa, dextroamphetamine, and lisdexamfetamine. Levodopa-carbidopa has been studied for the treatment of cocaine use disorder because of its ability to increase brain dopamine levels and subsequently correct cocaine-induced hypodopaminergia. Levodopa is able to cross the blood-brain barrier but is administered with carbidopa (a peripheral decarboxylase inhibitor) to slow the breakdown of levodopa and allow a greater portion of it to enter the brain rather than being metabolized to inactive compounds.

The DÎ²H gene polymorphism rs1611115 has been studied for pharmacogenetics matching with levodopa.

 This functional, regulatory polymorphism leads to a substantial 10- to 100-fold reduction in the amount of the DÎ²H enzyme. With substantially lower DÎ²H levels, the conversion of dopamine to norepinephrine is much slower and lower than normal. For patients with the low DÎ²H activity genotypes (CT/TT) who were treated with levodopa, the odds of having cocaine-positive urine samples decreased significantly, compared with placebo. Individuals with the normal DÎ²H activity genotype (CC) showed no differential levodopa response between active agent and placebo.

Dextroamphetamine, an amphetamine derivative, has also been studied for its ability to correct hypodopaminergia and decrease D2 receptor binding observed with chronic cocaine use.

 However, dextroamphetamine does this via reversal of the dopamine transporter, which results in indirect enhancement of dopaminergic function.

Lisdexamfetamine dimesylate is a prodrug consisting of dextroamphetamine covalently bonded to the amino acid lysine. Following oral administration, red blood cells convert lisdexamfetamine into dextroamphetamine (the active drug) by enzymatic rate-limited hydrolysis of lysine from amphetamine. The kinetics of the rate limiting is such that the medication has long-lasting effectiveness but a slow onset, similar to a sustained-release amphetamine preparation.

 Study participants who received lisdexamfetamine reported less need for cocaine than those given placebo.

 Although cocaine use did not differ between the lisdexamfetamine and placebo groups, lisdexamfetamine recipients reported significantly less craving than those given placebo.

Noradrenergic agents include doxazosin, disulfiram, and nepicastat. Doxazosin, which blocks noradrenergic alpha-1 receptors, has been studied in the treatment of cocaine use disorder for its ability to reduce the acute effects of cocaine. When rapidly titrated, doxazosin significantly reduced cocaine use and increased the percentage of participants who achieved 2 or more consecutive weeks of abstinence.

 Slow titration of doxazosin was found to be similar to that of placebo. This suggests that the medication effect is due, in part, to the rapid titration to the optimal dose, rather than to a longer duration of receiving the optimal dose.

A subsequent study of doxazosin (under review) not only replicated its efficacy for reducing cocaine use, but also showed that this efficacy was enhanced in patients with relatively common genetic variants in the alpha-1 receptor, which appears to change the G-protein coupling of this receptor to the cyclic adenosine monophosphate second messenger system.

Disulfiram also acts on both the noradrenergic and dopaminergic systems by inhibiting the enzyme (DÎ²H) that converts dopamine to norepinephrine through chelation of the copper needed for its activity. Disulfiram at 250 mg daily has significantly reduced cocaine use in several clinical trials.

 More recently, disulfiram has been studied in conjunction with polymorphisms in the genes that encode for DÎ²H, as well as the ANKK1, the dopamine receptor D2 (DRD2), and the Î±1-adrenoceptor gene variations.

The reduction in cocaine use with disulfiram was associated with a specific functional regulatory genetic polymorphism in the gene that codes for DÎ²H (rs1611115). Patients who have 2 of the alleles associated with normal levels of DÎ²H (CC) responded to disulfiram, while those with the genotypes encoding lower levels of DÎ²H (CT and TT) showed no difference from placebo.

genes are associated with dopamine D2 receptor sensitivity to dopamine. Patients with CT or TT variants of the ANKK1 genotype had a significant decline in cocaine-positive urine samples on disulfiram; patients who received placebo showed no treatment effect; patients with the CC variant of the ANKK1 genotype showed no effect on treatment with disulfiram or placebo. Using the DRD2 genetic variants, the GT/TT genotype group showed a significant decrease in the number of cocaine-positive urine samples on disulfiram, whereas the GG genotype group showed only a marginal decrease. Moreover, genotype pattern analysis revealed that individuals carrying at least 1 minor allele in either gene (

) responded better to disulfiram treatment than did individuals carrying only the major alleles.

Disulfiram inhibition of DÎ²H decreases brain norepinephrine levels, leading to a subsequent reduction in stimulation of adrenoceptors. The gene 

-adrenoceptor has a functional polymorphism (rs1048101) in exon 2 and codes for 2 types of receptors based on a single amino acid substitution of ARG for CYS. The more common CYS receptor appears to have a more efficient G-protein coupling to the cyclic adenosine monophosphate second messenger system than does the ARG receptor variant.

 We found that the more common variant with CYS was associated with a significant difference from placebo in response to disulfiram, while the ARG variant showed no difference between disulfiram and placebo.

Because we had already found that the DÎ²H CC genotype was associated with an enhanced pharmacogenetic response to disulfiram, we decided to combine both the DÎ²H-CC and ARDA1A-TT/TC genotypes to form a group of patients with both of these potentially responsive genotypes.

 The patients with the responsive polymorphisms for disulfiram again showed a significantly enhanced reduction in cocaine urine samples compared with a minimal change on placebo. In the remaining patients, including those with only 1 of these 2 responsive polymorphisms, no difference was seen between disulfiram and placebo. Thus, the optimal response to disulfiram appears to be among those patients with both the “normal” CYS polymorphism of the alpha-1 adrenergic receptor and the genetically normal, rather than low, DBH levels.

Nepicastat, a potent and selective DÎ²H inhibitor, has also been investigated, but it did not change the kinetics, metabolism, or clearance of cocaine or its metabolites.

 In addition, the lack of effects of nepicastat on the cardiovascular and pharmacokinetic profiles evoked by cocaine suggests that the selective targeting of nepicastat for the DÎ²H enzyme would improve the safety profile of this compound compared with the non-selective DÎ²H inhibitor disulfiram. In an as yet unpublished study, nepicastat significantly reduced several cocaine-induced positive subjective effects.

Among mixed mechanism agents that have been investigated for the treatment of cocaine use disorder, the most successful has been modafinil.

 Modafinil inhibits dopamine and norepinephrine transporters and increases extracellular levels of glutamate. It has been studied for its impact on cocaine use and its ability to decrease symptoms of cocaine abstinence syndrome.

 Patients treated with modafinil reported low levels and shorter durations of cocaine craving intensity on the Brief Substance Craving Scale. Patients were also more likely to rate themselves as “very much improved” on the Clinical Global Impression Scale, compared with placebo.

 No pharmacogenetics analyses have been undertaken with modafinil, but clearly the functional polymorphisms for the dopaminergic, noradrenergic, and possibly glutaminergic systems deserve study.

The medical comorbidities associated with cocaine use disorder include greater risk of infectious diseases and greater rates of health care utilization.

 The treatment of cocaine use disorder needs FDA-approved medications, but the evolving pharmacotherapies have not been uniformly successful and may need to be applied to subgroups of patients to be optimally effective.

The emergence of effective pharmacotherapies requires matching medications to optimal patient groups. Genetic markers can be used to advance identification of patients for this type of personalized medicine. Thus, in addition to targeting multiple neurotransmitter systems, current pharmacotherapy research incorporates pharmacogenetics to identify subpopulations that might preferentially respond to specific medications. New challenges include matching medications such as modafinil, which targets multiple neurotransmitter systems, to genetically selected subgroups of patients.

Dr Andry is Addiction Psychiatry Fellow, Dr Shorter is Assistant Professor, and Dr Kosten is JH Waggoner Chair and Professor of Psychiatry, Neuroscience, Pharmacology, Immunology & Pathology and Co-Director, Dan Duncan Institute for Clinical and Translational Research at the The Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine in Houston, TX. Dr Kosten is also Editor of the 

. The authors report no conflicts of interest concerning the subject matter of this article.

Center for Behavioral Health Statistics and Quality. Behavioral Trends in the United States: Results From the 2014 National Survey on Drug Use and Health

. Washington, DC: US Department of Health and Human Services; 2015. HHS Publication No. SMA 15-4927, NSDUH Series H-50.

http://www.drugabuse.gov/related-topics/trends-statistics

 Shorter D, Domingo CB, Kosten TR. Emerging drugs for the treatment of cocaine use disorder: a review of neurobiological targets and pharmacotherapy. 

 Liu S, Green CE, Lane SD, et al. The influence of dopamine Î²-hydroxylase gene polymorphism rs1611115 on levodopa/carbidopa treatment for cocaine dependence: a preliminary study. 

 Pennick M. Absorption of lisdexamfetamine dimesylate and its enzymatic conversion to d-amphetamine. 

 Mooney ME, Herin DV, Specker S, et al. Pilot study of the effects of lisdexamfetamine on cocaine use: a randomized, double-blind, placebo-controlled trial. 

 Shorter D, Lindsay JA, Kosten TR. The Alpha-1 Adrenergic Antagonist Doxazosin for Treatment of Cocaine Dependence: a pilot study. 

 Kosten TR, Wu G, Huang W, et al. Pharmacogenetic randomized trial for cocaine abuse: disulfiram and dopamine beta-hydroxylase. 

 Carroll KM, Nich C, Ball SA, et al. Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram. 

 George TP, Chawarski MC, Pakes J, et al. Disulfiram versus placebo for cocaine dependence in buprenorphine-maintained subjects: a preliminary trial. 

 Spellicy CJ, Kosten TR, Hamon SC, et al. ANKK1 and DRD2 pharmacogenetics of disulfiram treatment for cocaine abuse. 

 Shorter D, Nielsen DA, Huang W, et al. Pharmacogenetic randomized trial for cocaine abuse: disulfiram and Î±1A-adrenoceptor gene variation. 

 De La Garza R 2nd, Bubar MJ, Carbone CL, et al. Evaluation of the dopamine Î²-hydroxylase (DÎ²H) inhibitor nepicastat in participants who meet criteria for cocaine use disorder. 

Prog Neuropsychopharmacol Biol Psyhciatry

 Kampman KM, Lynch KG, Pettinati HM, et al. A double blind, placebo controlled trial of modafinil for the treatment of cocaine dependence without co-morbid alcohol dependence. 

There are no FDA-approved pharmacotherapies for cocaine use disorder. Here: a review of the off-label use of promising medications for this addiction.

Emerging Treatments and Pharmacogenetics for Cocaine Use Disorder

FROM THE AMERICAN ACADEMY OF ADDICTION PSYCHIATRY

[[{"type":"media","view_mode":"media_crop","fid":"43418","attributes":{"alt":"prescription_Burlingham/shutterstock.com","class":"media-image media-image-right","id":"media_crop_9894157225487","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5704","media_crop_rotate":"0","media_crop_scale_h":"80","media_crop_scale_w":"120","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Burlingham/shutterstock.com","typeof":"foaf:Image"}}]]Although boundaries are essential in the treatment of addiction, drug policy, and life in general, an unthinking devotion to rules and protocols produces disastrously rigid addiction treatment and public policy. In the simple case of medication dosages, clinicians are well aware that a small minority of patients who are rapid metabolizers, or who have developed tolerance to a medication, may well need dosages far above the published guidelines. In the more complex scenarios of treatment selection, some patients may benefit from referral to a peer-led support group; others may benefit from professional therapy, and still others succeed with the simple prescription of an anti-addiction medication-but most require multiple such interventions.

Addiction treatment is not a one-size-fits-all endeavor.

Boundaries in addiction psychiatry run the gamut from mandatory legal obligations, to well-accepted clinical guidelines, to the mere suggestions of clinicians. And although even laws are open to interpretation, written standards of any sort become part of the national standard of care that physicians are expected to meet or exceed-even if they do not carry the force of law. There is a vast range of legitimate approaches to addiction and substance misuse, although clinicians rightly fear official censure, legal action, or malpractice litigation if rules are not followed.

Given the potential for complications with the treatment of addicted patients-and their penchant for getting caught up with the law-boundaries are important, not least because psychiatrists must put on the mantle of authority and reassure and guide patients, perhaps more than in other specialties. Treatment modalities that are not only effective but also demonstrably well accepted in the field help the clinician convince the patient and his or her family to take the leap toward sobriety.

Clinicians who specialize in treating addiction are constrained by a variety of laws and regulations designed to protect patient confidentiality, avoid the diversion of dangerous medications, and ensure the provision of excellent care. Some of these rules are hard-and-fast: buprenorphine prescribers must have the Drug Addiction Treatment Act of 2000 (DATA-2000) waiver, patient confidentiality under the Health Insurance Portability and Accountability Act and the Code of Federal Regulations Title 42 is sacrosanct, and current medical licensure is obligatory for physicians. With our ability to prescribe powerful and potentially addictive medications, we can endanger our patients, the public, and ourselves if we ignore the applicable regulations.

However, in all but the most obvious of scenarios, conflicting obligations complicate our adherence to laws and regulations. When should confidentiality be breached for the addicted person who is harming himself with drugs or alcohol? Different clinicians, quite naturally, have different thresholds for what is enough of an emergency to warrant a no-permission call to the patient’s family or to the 911 dispatcher. And while medication dosages should usually adhere to published guidelines, most clinicians prescribe unusual dosages sometimes, thereby stepping outside of the usual standard of care in hopes of helping their patient.

Clinical traditions and lore are important, but they can become ossified as the “right way to treat addiction.” So, we need to turn a sharp, skeptical eye on treatment models handed down from our teachers, methods popular among the general public, and media-driven paradigms such as the 

for being both an accepted if poorly researched paradigm and a wildly popular media sensation.

Peer-led support groups such as Alcoholics Anonymous don’t claim to be treatments but are widely misperceived as the most, if not the only, effective model for the treatment of addiction. A notorious failed model of addiction treatment was Synanon, whose cult-like beginnings engendered more mainstream and effective treatments such as the Therapeutic Community model in use today by Phoenix House, Daytop Village, and others. Groundbreaking books (eg, 

) and catchy slogans such as “addiction is a 

 can mislead by simplifying complex phenomena.

Although efforts to destigmatize addiction by pointing out its biological aspects are certainly laudable, those attempts ignore some of the less-quantifiable aspects of addiction that also need to be addressed for most people with substance-use disorders. This is not to say that people who suffer from addiction are spineless or immoral, only that their condition usually needs more than a pharmacological solution! So, there is little value in relying on unproven or simplistic notions about addiction therapy, whether they are pharmaceutical or psychosocial treatments.

By the same token, of course, evidence-based medicine can engender its own tyranny and cadre of true believers, whose reliance on data-driven models fails many patients with addiction. A recent book

 about the prevalence of “medical reversals”-the abandonment of a treatment because clinical experience demonstrates what good studies should have shown long before the treatment entered the market-outlines the strengths and weaknesses of medical research. The authors opine that these sorts of embarrassing and dangerous reversals could be avoided by rigorous and unbiased randomized, controlled studies, but they also lay out the multiple ways in which clinicians are misled by what appears to be definitive evidence of a treatment’s effect or lack thereof. Among these are bias introduced by the sponsors of a study, the use of surrogate endpoints that have little clinical meaning, and blind acceptance of single studies that, however convincing, cannot be replicated.

In the world of addiction, for instance, while the use of anti-craving medications such as naltrexone and acamprosate is well-supported by research, these medications are hardly a panacea for addiction, despite the contention by some that failing to prescribe them constitutes medical malpractice. More than that, the real-world effects of these medications are not entirely clear. Although data show a measurable effect size in decreasing the time to first drink and total amount of alcohol used, these surrogate measures do not tell us what we really care about: were the patient’s morbidity, mortality, and overall functioning improved?

Well-designed clinical studies often disprove previously hard-and-fast rules in medicine. And in any case, the data rarely define what to recommend to a certain patient, with a certain set of values, at a particular time. An unthinking fealty to the evidence base of our addiction practice can lead to missteps every bit as dangerous as reliance on unproven treatments or the pronouncements of senior clinicians.

 from the American Society of Addiction Medicine

 (ASAM) exemplify the sort of carefully constructed industry standard that must be a part of our clinical knowledge base but cannot and should not form a cookbook for treating addiction. For instance, the guidelines define those with comorbid psychiatric disorders as a “special population,” despite a consensus in the literature that about half of those who present for treatment of opioid addiction have a comorbid psychiatric disorder, making dual diagnosis more the rule rather than a “special” exception.

 Given the enormous variability of those who present with an addiction to opioids and a co-occurring psychiatric condition-ranging from schizophrenia to anxiety-no standard approach can apply. The ASAM guidelines inevitably, and correctly, contain recommendations for off-label medications, gut-level practical recommendations without clear scientific support, and some inadequately studied treatment regimens.

One conspicuous boundary in addiction treatment today is the legally dictated cap on the number of patients to whom a physician may prescribe buprenorphine. The regulations allow for physicians with a DATA-2000 waiver to prescribe for 30 patients and, after a year with the waiver in place, allow prescriptions for up to 100 patients. Some have argued that this cap denies treatment to patients in areas underserved by physicians with waivers, most commonly rural populations. There is no doubt that too few physicians prescribe buprenorphine, but simply eliminating the limit is an obvious and easy answer that is almost certainly also the wrong answer. Most physicians who now hold the waiver do not prescribe up to the limit, and it is a bit difficult to imagine comprehensive treatment of more than 100 patients by one clinician.

Rather than summarily abolishing the cap on the number of buprenorphine patients that one physician can treat, the American Academy of Addiction Psychiatry, along with the American Psychiatric Association and the American Osteopathic Academy of Addiction Medicine, advocates for a more measured change in the present regulations. This would involve:

• The abolition of the Drug Enforcement Administration inspections that many potential prescribers blame for their reluctance to prescribe buprenorphine

• The use of physician assistants and nurse practitioners in those practices that prescribe buprenorphine to large numbers of patients

• An exploration of telemedicine for buprenorphine prescriptions

• The expansion of federal funding for buprenorphine training

These nuanced modifications to the buprenorphine regulations are designed to expand the availability of buprenorphine while minimizing the risks of substandard treatment and diversion.

Although there are plenty of shrill and simplistic advocates on both sides of these sorts of debates, most realize that the truth usually lies somewhere between the poles of the simplistic (and simplifying) dichotomies we fashion for ourselves. In addition to obtaining the right education and experience for treating addicted people, clinicians must remain more cognizant than most of the rules and regulations that form the boundaries for our clinical interactions. Our patients are inveterate rule-breakers, and we should therefore promote a healthy respect for boundaries, while avoiding the slavishly rigid thinking that results in flawed public policy and clinical disaster. Keeping the well-being of the individual patient paramount will protect that patient from the foolish inconsistency of mechanistic medicine, and the concomitant danger of tradition-based superstition.

The author acknowledges the American Academy of Addiction Psychiatry (AAAP) for help with this article. AAAP is the premier organization for learning and sharing about the science of addiction psychiatry research and clinical treatment.

Dr Westreich is Associate Professor of Clinical Psychiatry in the division of alcoholism and drug abuse, department of psychiatry, New York University School of Medicine in New York and serves as the consultant on behavioral health to the Commissioner of Major League Baseball. He is Immediate Past President of the American Academy of Addiction Psychiatry. He reports no conflicts concerning the subject matter of this article.

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 Krausz M, Degkwitz P, Kuhne A, Verthein U. Comorbidity of opiate dependence and mental disorders.

 Rounsaville BJ, Weissman MM, Crits-Christoph K, et al. Diagnosis and symptoms of depression in opiate addicts, course and relationship to treatment outcome. 

Clinical traditions are important, but they can become ossified as the “right way to treat addiction.” So, we need to turn a sharp, skeptical eye on treatment models.

Addiction Psychiatry: Laws, Guidelines, and Suggestions

[Acknowledgment-the author acknowledges The 

Medication-assisted treatment (MAT) for addiction in the drug court system represents an outstanding, although as yet incompletely realized, opportunity for bringing state-of-the-art treatment to a population in desperate need. Because addiction and mental health treatment falls increasingly into the justice system for underserved and indigent patients, the drug courts can serve as an example for thoughtful, evidence-based care focused on the individual’s needs rather than on preconceived notions about the appropriateness of any particular treatment strategy.

Drug court professionals raise legitimate concerns about MAT such as diversion, adverse effects, ineffectiveness, and the potential for using MAT to decrease rather than entirely stop drug use. Unfortunately, drug courts do not utilize MAT (in particular methadone and buprenorphine) as much as they probably should. A 2010 representative sample of US drug courts found that although fully 98% of cases consisted of opioid-addicted individuals, only 48% were offered the opioid agonists buprenorphine and methadone.

The major barriers may be the cost of the treatment and court policy. Although there is usually little objection to non–dependence-forming medications such as naltrexone, naloxone, and acamprosate, maintenance medications such as methadone and buprenorphine more commonly provoke unease among drug court professionals. Only by addressing these concerns with available clinical research data, modified to the drug court system, can MAT be a potential life-saving treatment.

Drug courts are designed to divert non-violent offenders away from incarceration and into highly structured addiction treatment programs. By combining good addiction treatment with the threat of sanctions for non-adherence, the drug courts can use public resources to provide more effective and humane treatment than a simple “lock-em up” strategy. Drug courts improve the treatment outcomes of drug-abusing offenders by combining evidence-based treatment with strict behavioral accountability. By using both encouragement for improvement and sanctions for failures, drug courts have been able to address addiction problems in an enlightened manner that is demonstrably more effective than simply incarcerating the addict. About half of the 3400 US drug courts serve criminally involved adults in need of drug treatment, and they share a set of 10 principles, originally operationalized in 1997.

 These principles require, among other things, “Access to a continuum of alcohol, drug, and other related treatment and rehabilitation services.”

 The requirement of “a continuum of . . . treatment and rehabilitations services” imposes a condition that MAT be a part of the full range of services available to the defendant.

Opiate use among non–legally involved Americans remains at disturbingly high levels and has risen over the past 11 years: 681,000 adults acknowledged using heroin in 2013, and 1.9 million Americans met criteria for an opioid use disorder based on their use of prescription painkillers.

 In an unintended consequence of the government’s successful crackdown on inappropriate opiate prescribing, many addicts switched to heroin, with a subsequent increase in heroin-related overdose deaths. According to the Centers for Disease Control and Prevention, drug overdose deaths quadrupled between 2000 and 2013, with 43,982 such deaths occurring in 2013.

 Over the past 50 years there has been a shift in heroin use from low-income urban areas with large minority populations to predominantly white, affluent suburban and rural areas.

For those drug users who are legally involved, drug court settings are ideal for implementing MAT for opioid dependence-the individuals who appear in drug court need treatment rather than incarceration. The drug courts strive to combine the best evidence-based therapies with strict behavioral accountability and long-term mandatory follow-up.

 Throughout the US, drug courts have worked with large numbers of opioid-dependent persons: one survey of 2459 courts nationwide found that 7% of participants listed illicit opioids as their primary drug of abuse, compared with 10% in suburban courts and 12% in rural drug courts, tracking the national trend toward non-urban use of opioids.

 The national numbers indicate that more opioid-dependent drug court participants were dependent on prescription opioids (66%) than on heroin (26%).

MAT is one of many standard-of-care treatments for addiction: the DATA 2000 Act allows qualified physicians to prescribe or dispense buprenorphine, for the first time allowing use of a narcotic for addiction treatment outside of the traditional methadone clinic system.

 The Act allows for more effective treatment of opiate addiction; however, (unintentionally) it has also resulted in increased illicit use, diversion, and overdose with buprenorphine. Official government publications detail best practice guidelines for the use of buprenorphine, and newer studies have defined, among other things, the efficacy of buprenorphine in staving off relapse as well as the patient characteristics that predict best treatment outcomes.

Buprenorphine and methadone have a stable if somewhat controversial place in the general anti-addiction pharmacopeia. Drug court data show that the 2 agents are no less effective in the court system compared with outside the court system, because of the particular characteristics of the drug court treatment, ie, behavioral accountability. One survey of family drug courts specifically designed for child abuse/neglect/endangerment cases found that addicts in the program were more than 20% more likely to complete treatment, and 40% more likely to have a reunited family.

 In addition, there were huge cost savings because of less reliance on out-of-home child placements. Other MATs for addiction are used in drug court situations, including extended-release injectable naltrexone and others, all of which benefit from the court’s ability to mandate clinically appropriate care.

Although drug courts are designed to reduce the incarcerated population, the courts are limited by “tight eligibility requirements, specific sentencing requirements, the legal consequences of program noncompliance, and the constraints in drug court capacity and funding.”

 These eligibility requirements usually consist of rules about the nature of the criminal act, and the number of previous convictions. By allowing more access to drug courts for defendant/patients who require MAT, at least the most obvious bottleneck in bringing addicts to treatment will be diminished.

The relative paucity of opioid treatment programs that drug courts can utilize is also a problem. A study of 23,141 methadone patients in 84 opioid treatment programs found that 40% of patients traveled more than 10 miles to their clinician, and 6% traveled from 50 to 200 miles to obtain prescribed medication.

Drug court leaders promote the idea that MAT should be one of the modalities available to participants, and that not having MAT available is a breach of best practices. In the official publication of the Adult Drug Court Best Practice Standards Committee, the authors note that:

Best practices include psychotropic or addiction medications based on medical necessity as determined by a treating physician with expertise in addiction psychiatry, addiction medicine or a closely related field. . . . Medically assisted treatment can significantly improve outcomes for addicted offenders. . . . Buprenorphine or methadone 

 [author’s italics] administered prior to or immediately after release from jail or prison has been shown to significantly increase opiate-addicted inmates’ engagement in treatment and reduce illicit opiate use, re-arrests, technical parole violations, and recidivism as well as mortality and hepatitis C infections.

The leaders of the drug court movement have concurred with the addiction field’s assessment that MAT, including maintenance opiate treatment, can be a valuable component of addiction treatment; sophisticated treatment facilities outside the drug courts also promote diverse evidence-based treatment that includes buprenorphine or methadone. A study of drug court policy in New York State found that patients were required to taper off methadone after an arbitrary period, and that there was profound stigma against opioid maintenance. The authors opined that the “forced ‘tapering’ from methadone, and buprenorphine, or blanket exclusion from thirst treatment, show the danger of what happens when judges play doctor.”

 (This is a frequent jeremiad against drug court judges, although the judges are usually following the abstinence-only recommendations of clinical personnel within the court system, who may themselves need further education about MAT.)

One advocacy group went further and suggested that a failure to allow MAT, whether as a court’s blanket policy or in an individual case in which MAT is clinically indicated, violates the Americans With Disabilities Act and the Eighth Amendment’s prohibition of cruel and unusual punishment, although there is no legal precedent for this perspective.

 From the funding angle, the Office of National Drug Policy implied that MAT will be a required modality to ensure continued public funding of the drug court system. Its director, Michael Botticelli, said, “If you are getting federal dollars . . . you need to make sure that people have access to these medications and that we’re not basically making people go off these medications, particularly as participants of drug court.”

Despite the official and growing acceptance of MAT among drug court professionals, there is not enough access to MAT owing, at least in part, to a dearth of licensed practitioners who are willing and able to treat drug court participants. Judges complain that this scarcity of licensed providers limits their ability to integrate MAT into their decisions. The lack of buprenorphine prescribers, especially in non-urban areas, is a problem nationwide and has led to calls for lifting the 30-patient limit for buprenorphine.

Advocates claim that the 30-patient limit disproportionately affects the poor, has the potential for causing premature discontinuation of treatment, and is a disincentive for physicians to devote their entire practice to using buprenorphine to treat addiction. Interestingly, the reason prescribers cite for not making buprenorphine their main clinical focus is the exact reason given by those who oppose lifting the cap, the rationale being that physicians who only prescribe buprenorphine will be incapable of, or unwilling to, provide comprehensive care.

Further acceptance of MAT in the drug courts will depend on the continuing education of personnel including judges, prosecutors, and clinicians, as well outside consulting clinicians who provide needed evaluation, treatment, and support. The education must include the science of addiction and MAT, the spectrum of treatment approaches available, and case studies that demonstrate the realities of using MAT and other treatments for addiction. Those who do training and education within the court system must acknowledge the reality that MAT is not a panacea but rather one of many useful and evidence-based weapons in the struggle against addiction.

In addition to education, clinicians who interact with the drug court system need to know more about the obligations of courts that are entrusted with the task of protecting society and have the power to bring lawbreakers to account for their actions. Only with this ideal of therapeutic jurisprudence-collaboration between the clinical and legal worlds for the benefit of both defendants and the larger society-can drug courts live up to their vast potential for delivering good care to persons with addiction disorders.

Dr Westreich is Associate Professor of Clinical Psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine in New York and serves as the consultant on drugs of abuse to Major League Baseball. He is President of the American Academy of Addiction Psychiatry. He reports no conflicts of interest concerning the subject matter of this article.

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Addiction and mental health treatment has fallen increasingly into the justice system for underserved and indigent patients. How do we bring state-of-the art treatment to this population in desperate need?

American Academy of Addiction Psychiatry

Articles

Coaching Families to Address Addiction

Emerging Treatments and Pharmacogenetics for Cocaine Use Disorder

Addiction Psychiatry: Laws, Guidelines, and Suggestions

Medication-Assisted Treatment and Drug Courts