To describe basic pharmacological treatments for nicotine, alcohol, and other drugs.
The following discussion of Pharmacotherapy is reproduced with permission from the proceedings of the Josiah Macy, Jr. Foundation sponsored conference on Training about Alcohol and Substance Abuse for All Primary Care Physicians.
Physicians should be skilled in the pharmacological treatment of nicotine, alcohol and drug dependence. This includes the management of drug withdrawal, post-withdrawal abstinence syndromes, drug maintenance, and co-morbid conditions.
Alcohol or Drug Withdrawal
The primary drugs that usually require acute pharmacological interventions
to treat withdrawal symptoms include tobacco, alcohol, sedatives,
stimulants, and opioids. Other mood-altering drugs such as cannabinoids,
PCP, hallucinogens, inhalants, and anabolic steroids are not usually
associated with withdrawal symptoms that require medication. Some
patients who use these drugs may benefit from pharmacotherapy
after cessation of drug use.
A number of principles underlie the management of tobacco, alcohol, and drug withdrawal. Early pharmacological treatment can reduce the frequency and magnitude of drug withdrawal complications. Most patients identified in a primary care setting can be safely detoxed in an outpatient setting. Patients who develop the clinical picture of drug withdrawal need a comprehensive medical assessment, including a blood alcohol level and urine drug screen. Supportive, empathic care is an essential component of acute withdrawal management. Pharmacological treatment is only one component of a comprehensive treatment plan and should never be used as the sole treatment modality.
Symptoms of tobacco withdrawal can be managed using nicotine replacement patches with minimal side effects. Cessation rates are higher when patches are used in combination with other methods. Alcohol and sedative withdrawal can be life-threatening and is associated with seizures, psychosis, delirium, and violent behavior. Other serious complications include aspiration pneumonia, respiratory arrest, and cardiovascular collapse. High doses of a cross-tolerant drug such as a benzodiazepine is the drug of choice for treating such withdrawal. Loading doses administered orally is the preferred treatment method.
No one certain medication will block the effects of withdrawal
from cocaine or other stimulants. Specific symptoms, such as agitation,
paranoia, and nausea, should be treated with medications directed
at these symptoms. Severe paranoia and suicide attempts should
be anticipated and appropriate safety measures instituted. Treatment
of opioid withdrawal depends on the drug used and the severity
of symptoms. Patients on low doses of oral narcotics can be safely
withdrawn in a few days on an outpatient basis. Persons on higher
doses of narcotics can usually be tapered off their primary drug
in less than 10 days. Symptoms can be treated with a number of
medications directed at specific findings. For example, clonidine
will block many of the adrenergic signs. Individuals on methadone
maintenance programs may require a three-to-six month detoxification
plan in order to avoid severe withdrawal and relapse. Newborn
infants of women on methadone can be safely withdrawn with Phenobarbital.
Post-Withdrawal Craving and Abstinence Syndromes
Pharmacological intervention may help reduce the high rate of
relapse associated with tobacco, alcohol, and other drug dependence.
While the physiological and psychological responses to abstinence
are not well understood, craving appears to be distinct from other
problems such as sleep disorder, mood changes, anxiety, and memory
lapses, that occur in the post-withdrawal period. In contrast
to these chronic effects, abstinence-induced craving is short-lived
and frequently occurs in response to cues or environmental stimuli
associated with previous use. Medications currently used to treat
this problem include nicotine replacement for tobacco cessation
and Naltrexone for alcohol cravings.
Drug Maintenance
Drug agonists or cross-tolerant drugs are often used in opioid-dependent
patients in an attempt to substitute a less harmful drug for the
primary drug. The primary example of this technique is the use
of methadone for narcotic addiction. The rationale for drug maintenance
is based on the clinical observation that many addicts are unable
to stay drug free. Clinicians assume that these individuals have
irreversible changes in their central nervous system, and/or mental
health disorders that do not respond to abstinence-based methods.
The only commonly used drug maintenance program in the U.S. is for opioid dependence. For a physician to be able to place a patient on methadone maintenance, the patient must have been opioid dependent for at least the last year. Recently, the requirements have become less stringent and primarily are left to the discretion of a physician with a program license. Physicians currently are not licensed to prescribe methadone for maintenance except through a licensed methadone treatment program.
While benzodiazepines continue to be used for their agonist
properties, they have not been shown to help alcoholics or addicts,
with the exception of these with severe anxiety disorders. While
no specific cocaine agonists have been discovered, several drugs
may be helpful as cocaine replacements to reduce craving. These
include dopaminergic drugs such as bromocriptine.
Co-morbid Conditions - Pharmacological Treatment of Health
Effects
While treatment of conditions that are associated with alcohol
use are beyond the scope of this paper, a few facts should be
discussed. First, anxiety and panic disorders are very common
in persons using alcohol and other drugs. Sedative drugs should
be used with extreme caution because they often increase alcohol
and drug use and they have minimal effect on anxiety disorders
in this population. Hypnotics do not help for sleep disorders
associated with alcohol and drug use because they have mood-elevating
effects; even over-the-counter hypnotics can precipitate a relapse.
Depression will normally clear with abstinence. If depression
continues after a period of sobriety, a course of antidepressants
may be indicated. Treatment of medical conditions such as alcohol-associated
hypertension should include a period of abstinence to determine
the effect of alcohol on the patient's hypertension. Liver transplantation
should be considered in persons with alcohol-induced liver failure
who have been abstinent for six months.
Other Pharmacotherapeutic Agents
The opioid receptor naltrexone is used to block the effects of
heroin and other opioids at the level of the mu receptor. There
are three primary indications. First, it is used to reverse the
effects of opioids in cases of drug overdoses because it can reverse
the respiratory effects within seconds of reaching the central
nervous system. It may have to be given repeatedly or as an intravenous
drip in persons using long acting opioids, such as methadone.
The second indication is for relapse prevention following withdrawal
from all opioids. It is used as an adjunct to counseling and other
treatment. In motivated patients, such as impaired professionals,
it can be an effective deterrent.
A third primary indication is to accelerate the process of narcotic withdrawal. It is given in combination with buprenorphine in a controlled treatment setting. It can precipitate severe withdrawal, however, and should be done in consultation with an Addiction Medicine specialist. It may be especially helpful in patients who have failed the normal withdrawal protocols.
Antabuse is a medication used in the post-withdrawal period to reinforce sobriety from alcohol. Daily use of Antabuse may be helpful in reducing relapse rates. Drug interactions, hepatic toxicity, and severe reactions in patients who drink while taking the medication, complicate the clinical usefulness of this metabolic inhibitor.
For more information on particular drugs mentioned above go to your search engine (I prefer LYCOS and type in the name of the drug you are interested in. You will usually find a nice list of possible "hits" that will give you lots of useful information on the properties of the drug.
Here is a short list of some drugs that are of current interest in the substance abuse world. Just click on the name to learn more about it.
Study Questions:
In addition to the material presented above be sure to review Charles P. O'Brien's article, A Range of Research-Based Pharmacotherapies for Addiction.
Essay Questions: