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Chapter 18

Chapter 18.doc

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Wilfrid Laurier University
Bruce Mc Kay

Chapter 18 Treating Substance Abuse and Dependence • The Social and Economic Costs of Alcohol and Other Drugs in Canada o Prominent health issue in Canada o 2 million Canadians may meet the diagnostic criteria for being dependent on or having abused alcohol and other drugs • Pharmacotherapies (Medication Treatments) o Substance abuse and dependence are increasingly being viewed as “brain diseases” much like Parkinson’s disease o Majority do not become dependent o All individuals who lose greater than 80% of nigrostriatal dopamine neurons will exhibits symptoms of Parkinson’s disease o Most experts do not believe that pharmacotherapies alone with cure a chronic, relapsing disorder, such as substance abuse, in part, because the problem of substance abuse is expressed behaviorally • Detoxification (Withdrawal Management) and Maintenance Phase o Pharmacological interventions are typically initiated at two different phases of the dependence cycle:  Detoxification: initial and immediate goal during which medications are administered to alleviate unpleasant withdrawal symptoms that may appear following abrupt cessation of drug use  Maintenance: used in the detoxification phase are also sometimes used in the maintenance phase o Maintenance on pharmacological agents can be viewed as a longer-term strategy used to help the dependent individual avoid relapsing to the abused drug o Three major maintenance strategies are used  Agonist or substitution therapy: cross tolerance to the abused drug  Antagonist therapy: used to produce extinction by preventing the user from experiencing the reinforcing effects of the abused drug  Aversion therapy: used to produce an aversive reaction following ingestion of the abused drug o Disulfiram: (antabuse) for the treatment of alcohol dependence is an example of aversion therapy  Inhibits aldehyde dehydrogenase, a major enzyme involved in alcohol metabolism which with alcohol can produce unpleasant symptoms: vomiting, headache, breathing difficulties  In 2001 disulfiram was discontinued in Canada by manufacturer • Alcohol o Pharmacotherapies become increasingly important in treatment of alcohol dependence o Symptoms characterized by: tremors, tachycardia (rapid heartbeat), and hypertension, profuse sweating, insomnia, hallucinations, and seizures o Symptoms show after 6 to 24 hours of alcohol intake, peak at 72 o High degree of cross-tolerance between alcohol and the benzodiazepines o Three medications have received approval by Health Canada for treatment of alcohol abuse and dependence  Disulfiram (antabuse)  Naltrexone (Revia)  Acamprosate (Campral) o Latest medication to get approval for the treatment of alcohol use:  Acamprosate, a compound that bears a structural resemblance to GABA • Nicotine o More than 98% of tobacco users are cigarette smokers o 400 chemical components, nicotine primary reason for continued use o Pharmacotherpies used to reduce symptoms o Currently there is no evidence to suggest one treatment works better than the other o Treatments currently act in the brain to block the rewarding properties of or reduce withdrawal symptoms from drugs of abuse • Opioids o Opioid withdrawal is not life threatening, symptoms like nausea, vomiting, diarrhea etc are unpleasant o Opioid-dependent individuals are anaesthetized and, while unconscious, are given an opioid antagonist, so that withdrawal will occur while they are unconscious o Methadone: opioid analgesic  Commonly used o Buprenorphine, partial opioid antagonist  Relatively large margin of safety  Low overdose potential • Methadone o Alleviates symptoms of opioid withdrawal, and decreases chronic craving for opioids o Reduces the euphoric effects of other opioids (cross tolerance) o Should decrease client’s use of other opioids while involved with methadone • Buprenorphine o Opioid agonist/antagonist or partial antagonist at the mu receptor o Helps manage cravings associated with opioid withdrawal • Cocaine o Withdrawal Symptoms:  Depression  Nervousness  Dysphoria  Irritability  Cravings for cocaine o Vast majorities of medications assessed have no been effective at treating cocaine withdrawal symptoms of dependence o Modafinil’s, is being used recently, therapeutic actins are unknown, appears to increase the activity of several neurotransmitters and decrease the release of GABA  Not approved by Health Canada • Cannabis o Problems with frequent use o 1/11 users will become dependent o Withdrawal symptoms: irritability, anxiety, sleep, disruptions, and aches o Treatment drug: Dronabinol  Reduced sympt
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