Addiction Treatment in 2006
by Robert F. Proctor, M.D.

Alcoholism – Drug Addiction – Substance Abuse – Chemical Dependency  - These are some illnesses in which exposure to a mood altering chemical leads to an ongoing need to continue taking that chemical (addiction. The user repeatedly attempts to recreate a desired emotional state through continued use of their preferred chemical. Such biologic urges are so strong that even laboratory animals are readily addicted to the same substances to which man falls victim. Such chemicals include caffeine and nicotine, which may be stimulating or soothing (and most of us agree they are habit forming), alcohol, tranquilizers, narcotics and cocaine. Some of the moods sought include a high or exhilarated feeling, tranquility (stress relief), or sedation.

Sound attractive? It does to many. Thus the temptation to “try” these drugs. The bad news: if it sounds too good to be true, it probably is. After trying these chemicals, sometimes with as little as a single exposure, the mind and body are no longer content without the substance. Dependency is the condition of needing (and probably increasing) the use of the drug just to feel “normal”. The pattern, all to familiar, is that of devoting much time and effort to procuring, using, and recovering from under undesirable effects of the drug. Withdrawal from the abused substance leads to cravings (any of the substances); shakes, delirium tremens (a disorder involving sudden and severe mental changes), and seizures (from alcohol and benzos); or deep depression (from cocaine).

What’s New?
I’ll focus on two of the groups of research which have enhanced understanding and treatment of addiction disorders:

1. Which of us is at special risk of addiction? That alcoholism runs in the families is common knowledge. Recent studies show that genetic factors we inherit from our parents account for one half of the total risks of addiction disorders. We inherit a tendency to addiction in general, rather than to a specific drug such as alcohol. However, some genetic traits appear to relate to alcoholism. We know that alteration in genes for the metabolism or breakdown of alcohol are correlated with proneness to alcoholism.
   
   More recently, investigators are pursuing the connections between alcoholism and a disturbance of neurotransmitters. These body chemicals allow each nerve cell to communicate with it’s neighbors, necessary for our complex nervous system to function
   
   We know that the neurotransmitter serotonin us very important in mood disorders, particularly depression. Research using tryptophan depletion, which impairs serotonin production, has shown that this induced serotonin deficiency is associated with increased urge to drink alcohol. Similarly, a genetic variation in a serotonin transporter gene was found to be linked to increased alcohol and non-prescription drug use associated with stressful life events!
   
   Another neurotransmitter, GABA, is under active investigation to better understand its role in substance abuse and in mood disorders. The thread I see emerging is one of gaining understanding of the links between addiction and mood disorders.
2. Medications useful in addiction disorders are the subject of very active research. Well known drugs such as Phenobarbital and the benzodiazepines continue to be the best drugs for alcohol withdrawal (detoxification). Prior to skillful Detox procedures, there was a 1 in 4 chance of death in delirium tremens.
   
   Disulfiram (Antabuse) was the only approved medical deterrent to drinking for decades. Usefulness is limited by the need to take pills every day, and severe, potentially dangerous effects of drinking while taking Disulfiram. Interestingly, recent studies show a possible benefit in reducing cocaine abuse.
   
   Naltrexone blocks opiates (the narcotic family) at the Mu receptor (molecules that bind to opiates and cause specific physiologic effects) in the nervous system, and is beneficial in maintaining opiate abstinence. It was found, also, to block the euphoria (“high”) of drinking alcohol, and was approved by the Federal Drug Administration in 1992 for alcoholism. In research, comparing single and combined medications, Naltrexone was found to be the more effective drug for alcoholism.
   
   Reports in the past year appear to explain the observation that Naltrexone reduces alcohol craving. Cues to drinking, such as payday, peers, parties, bars and other drinking settings, and emotions, affect the nervous system in much the same way as taking the first drink. The body’s home grown opiates, called endorphins, triggered by the cue, produce the craving by stimulating (you guessed it) the Mu receptor. Note that Naltrexone occasionally causes side effects so it’s wise to do periodic laboratory work. The tablets may be taken once or twice a day. A long acting inject able Naltrexone has been studied and may be available this year.
   
   Acamprosate (Campral) is the medication newcomer to alcohol recovery programs. It seems to smooth out the neurotransmitter dysfunction caused by heavy alcohol abuse. It’s success implies that such dysfunction is involved in the high risk of relapse in alcoholism. Acamprosate benefit was not as robust as that of Naltrexone in a large comparison trial, but clearly enjoys a seat at the alcohol treatment table. It appears to be safe, and like Naltrexone, does not cause ill effects if one drinks while taking the medicine. It is taken 3 times daily.
   
   Opiate treatment research has brought good, even exciting news. Buprenorphine has opiate effects and opiate antagonist effects, again at the Mu receptor site. Opiate withdrawal studies found buprenorphine to be twenty-two times more effective than clonidine in achieving completed withdrawal success. The FDA has approved buprenorphine (Suboxone) for outpatient, medically managed, opiate Detox and, when indicated, opiate maintenance. After appropriate training, a physician may receive a waiver to prescribe buprenorphine for opiate dependent patients in the course of outpatient office care. I would stress three aspects of successful opiate recovery: whether a prompt (1 week or less) or more prolonged, tapering of buprenorphine is elected, the goal is abstinence. The withdrawal plan must be tailored to patient needs. The recovery process always includes counseling, likewise meeting the patients particular needs and schedule. Lastly, after successful opiate withdrawal, Naltrexone is prescribed over a lengthy period to help maintain recovery.

WHY DOESN’T SUCH TREATMENT ALWAYS WORK?
I’ve mentioned mood disorders and noted possible genetic and biochemical links to addiction. One specific mood disorder stands out as highly associated with addiction! Bipolar Disorder, in which mood changes may involve depression, euphoria, and anger, carries a sixty-one percent likelihood of substance abuse or dependency. Forty-one percent involve alcohol. A specific cause and effect relationship with addiction is not yet clear. Reasonably, each may adversely affect the other, Patients and mental health professionals both interpret significant drug and alcohol use in those with mood disorders as self medication, an attempt to relieve the distressing mood problems. Anxiety states, depression, and even psychoses are also associated with increased risk of substance abuse. It seems evident that dealing effectively with underlying mood disorders will greatly enhance success in addiction recovery.

WHAT SHOULD WE DO?
Each patient presenting with substance abuse/dependency problems is evaluated as a unique, complex, whole person. We must evaluate the chemical problem, determine medical issues by careful history and exam, and look at mood, emotional, and relationship issues via the biopsychosocial assessment. With this “whole person” assessment, the physician can address drug withdrawal, maintenance medication, and appropriate medication for anxiety, depression, sleep need, and mood stabilization.

The patient is a full partner in this process, with open discussion of the findings, diagnosis, and planned management. Success in addiction recovery is enhanced when the patient understands the factors which contribute to the addiction. Cognitive Therapy deals with the thought patterns that underlie our moods, and in turn determine our actions or behavior. When we understand the connection between circumstances, thinking, feelings, and behavior we become equipped to make better decisions. The new confidence in itself is a powerful weapon in the battle with addiction.

To summarize, addiction treatment has been greatly enhanced by the new medications, and by recognition and management of coexistent mood and anxiety disorders appropriate to the individual patient. Cognitive therapy during the recovery process completes the team approach that I consider the current standard of care.

For more information on addiction, contact Dr. Proctor at Assisted Recovery Center of GA, 7722 Waters Avenue 31306; (888) 570-6391

For Immediate Help Call (888) 570-6391