Recent Advances in Treatment

Feb 01, 2005

In the past decade, important advances have been made in detecting and treating substance abuse disorders. In addition, research has revealed influences on the etiology and course of SUDs. Dr Pettinati introduces this Addictive Disorders Special Report, noting that the articles add to this knowledge base.

Psychiatric Times

February 2005

Vol. XXII

Issue 2

Mental disorders and substance use disorders (SUDs) represent a major public health problem, and when these disorders are left untreated, they have devastating consequences for affected individuals, their families and society. While not widely known, a number of important advances have been made in the past decade toward understanding and treating SUDs and SUD-related disorders. For example, one of the more recent innovations in treating specific SUDs has been the addition of pharmacotherapy to improve treatment response, beyond what patients obtain from psychotherapy or counseling. The benefit of pharmacotherapy has now been well documented in the treatment of nicotine, alcohol, opiate and, just recently, cocaine dependence disorders.

Historically, addictive behaviors were considered a "deficiency in self-control" or the "result of ineffective thinking" (Steigerwald and Stone, 1999). While such perspectives are not widely held today, they have generated a number of useful and important remedial interventions that focused on spirituality, motivation and cognitive skill learning. The 12-step philosophy, typified by Alcoholics Anonymous, remains the most prevalent approach for changing alcoholic behaviors in the United States (Owen et al., 2003). Nonetheless, relapse rates in some settings remain high, and further investigation of alternative or adjunctive treatment options, such as pharmacotherapy, is of paramount importance.

In the past decade, the scientific community has come to better understand the neurobiological actions of excessive alcohol and drug use in the brain and the potential neurochemical disruptions associated with chronic, uncontrollable and excessive drug use. The scientific comprehension that an SUD is a chronic, biological disease (McLellan et al., 2000) has led to a conceptual mapping of drug-related constructs like craving, reward and high onto neurological substrates. This, in turn, has driven the investigation of the usefulness of pharmacological agents to reduce these constructs (Anton, 1999; Pickering and Liljequist, 2003; Swift, 1999; Volpicelli et al., 1995). In addition, we have learned that the etiology and course of SUDs are influenced by genetic heritability, biology, personal choice and environmental factors. Currently, further areas in the study of addictive behaviors have been identified that may be directly or indirectly related to substance dependence. These areas of study are summarized in this issue of Psychiatric Times.

Kyle M. Kampman, M.D., begins this Special Report with both data and optimism in identifying investigative pharmacotherapies for treating cocaine dependence. For the first time in over two decades of clinical trial research, there are several published controlled trials of various types of medications that have proven to be an advantage over counseling. Interestingly, the action of these medications varies widely. Among the brief list of proven medications is disulfiram (Antabuse), which is approved by the U. S. Food and Drug Administration for treating alcohol dependence. The author also describes an exciting and novel direction in treating cocaine dependence: a vaccine under development that is capable of stimulating the production of cocaine-specific antibodies that prevent the typical high or reinforcement from cocaine use.

Judith A. Richman, Ph.D., and Kathleen M. Rospenda, Ph.D., bring further into focus hidden alcohol or drug use as a coping response to the trauma experienced as a victim of sexual harassment. In this article, the authors describe the consequential substance abuse and dependency that can result from being a victim of sexual harassment.

Jeffrey N. Wilkins, M.D., provides us with a comprehensive summary of the pharmacotherapies that have been used to treat withdrawal and intoxication, as well as the rehabilitative stages of a wide spectrum of substance dependencies. He is quick to identify the medications that have been approved by the FDA for treatment of selected alcohol and drug dependencies. Wilkins then goes on to describe medications that, while approved for other uses, have been shown to be useful in treating selected substances in a particular stage of treatment (e.g., withdrawal as opposed to rehabilitation). Overall, this summary serves as a gentle reminder of the many pharmacotherapy options that are available to our patients. Wilkins provides us with practical knowledge that is useful to any physician who may have occasion to treat substance abuse in their practice.

The advances in this field that have been outlined in this Special Report will undoubtedly have an important impact on the way that problematic addiction-related behaviors and disorders are identified, treated and understood in the future.

Acknowledgement

It is with great appreciation that Psychiatric Times acknowledges Dr. Pettinati for her assistance in planning and reviewing this Special Report.

Dr. Pettinati is professor in the department of psychiatry Treatment Research Center at the University of Pennsylvania in Philadelphia.

References

Anton RF (1999), What is craving? Models and implications for treatment. Alcohol Res Health 23(3):165-173.

McLellan AT, Lewis DC, O'Brien CP, Kleber HD (2000), Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 284(13):1689-1695 [see comment].

Owen PL, Slaymaker V, Tonigan JS et al. (2003), Participation in alcoholics anonymous: intended and unintended change mechanisms. Alcohol Clin Exp Res 27(3):524-532.

Pickering C, Liljequist S (2003), Cue-induced behavioural activation: a novel model of alcohol craving? Psychopharmacology (Berl) 168(3):307-313.

Steigerwald F, Stone D (1999), Cognitive restructuring and the 12-step program of alcoholics anonymous. J Subst Abuse Treat 16(4):321-327.

Swift RM (1999), Medications and alcohol craving. Alcohol Res Health 23(3):207-213.

Volpicelli JR, Watson NT, King AC et al. (1995), Effect of naltrexone on alcohol "high" in alcoholics. Am J Psychiatry 152(4):613-615.

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