Emerging and Current Issues in the Treatment of Substance Use Disorders

December 18, 2014
Christina Brezing, MD

Given the pervasiveness of substance use disorders, the information provided here is relevant not only for addiction psychiatrists, but all mental health providers and primary care physicians.

The 25th annual American Academy of Addiction Psychiatry (AAAP) meeting assembled a fantastic group of presenters who put on high-quality, high-yield workshops and symposia, shining the light on current hot topics within the field of substance use disorders. The information provided is relevant not only for addiction psychiatrists, but all providers within mental health, given the pervasiveness of these disorders.

From reviewing the debate on electronic cigarettes to providing important new ways of thinking about substance abuse treatment in the context of co-occurring disorders, such as traumatic brain injury and chronic pain, the scope of the conference was broad and rich and those in attendance walked away with a wealth of knowledge (and a nice tan!).

A few major themes emerged from the meeting and include

(1) changes in US drug policies that ultimately impact the clinical scenarios we see, particularly with regards to marijuana and the impact these new laws will have on its citizens, which include in large part our patients

(2) novel treatment approaches of those “dually diagnosed”

(3) special populations that require integration of many individuals and disciplines in order to optimize patient outcomes. I had the pleasure to attend many of the workshops, symposia, paper, and poster sessions.

Here are some brief selected summaries from the many highlights at the meeting for the readers of Psychiatric Times.

Marijuana
In a presentation titled “Legalization of Marijuana: Are We Ready?”, Drs Kevin Hill from McLean Hospital, Richard Ries from the University of Washington, and Herb Kleber from Columbia University outlined the main points that every mental health care provider should have in their repertoire to allow for participation in the debate on legalization of marijuana. The presenters provided both the pros (tax revenue, decreased incarceration, and greater individual freedom) and the cons (increased health related costs, difficulty with determining safe levels for driving, fewer barriers to more users) of legalization of marijuana.

Interestingly, they reported that current polls identify that the majority (51%) of Americans are in favor of legalization of marijuana, which will include and capture our patients’ views. Knowing the issues will allow clinicians to have a dialogue with patients and colleagues outside of mental health and substance abuse on this growing trend.

A complement to this topic was a paper presentation by Dr Samuel Wilkinson, Gerrit van Schalkwyk, and Dr Cyril D’Souza from Yale on veterans’ attitudes about marijuana. Their interviews captured many of the misperceptions that patients have about marijuana including myths that it is not addictive, not associated with withdrawal, is natural, and overall has less of an effect on behavior than other substances.

This fast-growing trend of decreasing perception of harm leading to endorsements of legalization and ultimately more widespread use of marijuana was even further expanded by the symposium titled “What Is the Evidence of Harm to Adolescents Using Cannabis? A Critical Review of the Data.” Drs David Atkinson from the University of Texas-Southwestern, Christopher Hammond from Yale University, Kevin Gray from Medical University of South Carolina, Scott Krakower from Zucker Hillside Hospital, and Greg Tau from Columbia University honed in on the adverse health effects on one of the most vulnerable populations engaging in increased, regular cannabis use-adolescents. The symposium thoughtfully laid out the neurobiology of cannabis as an addiction in the young and developing brain, and the evidence of the role of cannabis in affective disorders, psychosis, and cognitive deficits in adolescents.

These adverse brain changes argue for the integration of care and sharing of knowledge among child and adolescent psychiatrists, addiction psychiatrists, pediatricians, and any other mental health or medical providers of care to this population, in addition to a call for more research into the impact of cannabis on this special population of youth.

Treatment strategies
Shifting focus to new treatment strategies for substance abuse and in particular for dual diagnosis patients, or patients diagnosed with both a substance use disorder and another co-occurring primary psychiatric disorder, Columbia faculty members Drs Adam Bisaga, Frances Levin, and John Mariani presented the workshop titled “Psychostimulant Treatment of Cocaine and Other Stimulant Use Disorders: Is It Time Yet?”

Before getting to the specifics of the topic at hand, the presenters did a wonderful job framing the key principles guiding the general use of medication assisted treatment of substance use disorders: (1) to reduce substance use and (2) to reduce the harms associated with substance use. These two ideas have fueled the use of agonist medication in the treatment of substance abuse, particularly opioids.

Using this concept and applying it to the treatment of cocaine use disorders, the faculty reviewed some preclinical and mostly clinical evidence for the use of oral psychostimulants, like D-amphetamine and methylphenidate in the treatment of cocaine use disorders. Notably, they highlighted the risks associated with this off-label use given the mixed and relatively limited literature on this topic. They made it clear that when considering this treatment for cocaine use disorder, the following treatment strategy should be used:

• include a thoughtful clinical evaluation of the risks and benefits
• assess trust between the physician and patient
• utilize a step-wise approach to medication selection first using reuptake inhibitors (such as modafinil, buproprion, and desipramine) that have less abuse potential
• if the above step-wise approach fails, then consider transitioning to monoamine enhancers, like methylphenidate and d-amphetamine with frequent monitoring and low supplies of medication provided at any given time

Dr Mariani encouraged the audience to think about their prescribing/treatment approaches on a spectrum of conservative to liberal, noting that conservative prescribers have less risk of misuse or diversion of their prescribed medications by patients but run the risk of under-treating their patients. In contrast, liberal prescribers would be much less likely to under-treat but ran a greater risk of their medication being misused or diverted. Ultimately, the goal is to find the “sweet spot” in prescribing practices to maximize treatment response and minimize misuse or diversion.

Following this concept of using psychostimulants for cocaine use disorder, Dr Levin showed new evidence from her soon-to-be published study looking at the use of higher dose monoamine enhancers, specifically d-amphetamine, in the treatment of cocaine use disorders in individuals with co-occurring ADHD. Not only did higher dose d-amphetamine improve ADHD symptoms as compared to placebo, it also led to greater abstinence from cocaine. Given the high co-occurrence of ADHD and substance use disorders and the negative bidirectional impact they have on health outcomes, she encouraged thoughtful screening to identify ADHD and substance use with appropriate interventions and treatment referrals.

Finally, on a similar note, Drs Denise Hien from City College of New York and Chaya Bhuvaneswaran from the University of Massachusetts-Worcester presented a workshop titled “Innovative Treatment Strategies for PTSD and Co-occurring Addictions.”Dr Hien emphasized the reciprocally reinforcing problem of PTSD and substance use disorders and the need to address both the effects of trauma and substance use in order to optimize patient-related outcomes. She reviewed a number of different evidence based psychotherapies including Seeking Safety, Concurrent Treatment with Prolonged Exposure (COPE), and Integrated CBT for PTSD-to to name a few-that have been found to synergistically improve PTSD symptoms and substance use when used in conjunction with medications like sertraline and prazosin.

Dr Bhuvaneswaran discussed the role of mindfulness training in the treatment of PTSD and substance use disorders with an emphasis on the attention to basic principles of mindfulness. She encouraged audience members to not feel compelled to spend large amounts of money on specialized mindfulness training, but rather to focus on the basic universal principles of mindfulness available to everyone for low cost and to take this into consideration when working with low socioeconomic patient groups.

It was an outstanding conference, and if readers find their interest piqued, I strongly encourage you to attend the AAAP Annual Meeting and/or the Addictions and Their Treatment Course next year in Huntington Beach, California-it will undoubtedly provide an in-depth perspective from the field of addiction psychiatry in the treatment of patients with substance use disorders within the context of mental health.

Disclosures:

Dr Brezing is a clinical and research fellow in the Division of Substance Abuse, Department of Psychiatry at Columbia University and New York State Psychiatric Institute in New York City. The author reports no conflicts of interest concerning the subject matter of this article.