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Substance Abuse Treatment

Detoxification is not treatment for addiction. Nobody cured an alcoholic or an alcoholic by detoxification. The critical issue in the treatment of addiction is preventing relapse. It is not detox. So letís try not to let the patient confuse that issue or confuse yourself on the issue. That being said, detoxification is clearly a critical medical management issue. Basically we look at varying ways of trying to wean people off medications that theyíve been abusing or alcohol or drugs and do it in ways that avoid either intoxication or withdrawal. It is, again, a trial and error process. You do an assessment, you start with clear-cut vital signs. You try varying doses. You adjust the doses depending on substance abuse treatment, alcohol, morphine, heroin, methamphetamines

The most important new changes here are the great merit of using withdrawal scales. Rather than simply checking pulse and blood pressure or kind of eye-balling the patient and guessing what the dose should be there are now very well worked out scales and Iíve included them in the syllabus and this measures a whole variety of symptoms. It looks complicated but you can teach nurses to use it

The reason that this is important is that if you use these scales, you often can get people through withdrawal not only faster but you will actually end up using less medication and that's been demonstrated a number of times and proven in some very adequate research models.

When you use the SEWA scale it helps you decide with the alcoholic how severe the problem is. If someone scores less than 8 on a SEWA scale you really do not need to medicate them at all. In fact, even up to 15 there are some patients that you might not want to medicate particularly if it was a very young person and the first time they had gone through withdrawal. 8-20 we consider mild to

Now let me talk briefly about acampersate. This drug has been in Europe for at least 10 years. Itís been highly successful. Itís used very much like naltrexone. It impacts on different systems. It seems to affect the GABA system and the NFDA receptors. We donít totally understand the neurobiology of why it works. We do know that it reduces craving and it reduces relapse. It is very well tolerated by patients. You donít get addicted to it. You donít get sedated. The final trials have been completed. I think everythingís already been submitted to the FDA or will be fairly shortly so I would expect sometime within the next year that this drug will probably be approved. Itís been used very safely in Europe for a long time and I think it will give us one more effective drug to add to the population.

Thereís another drug, nalmefene, which is another opiate antagonist. Also very early preliminary data that itís probably comparable to naltrexone except nalmefene is better tolerated and does not have any hepatotoxicity.

Now letís talk about dual diagnosis patients. This gets more complicated and Iíll try to go through this information in a way thatís helpful. First of all, with any of these other conditions, primarily anxiety disorders, primarily depression but also psychosis, all of these things can be precipitated, aggravated, induced, complicated by alcohol. Itís extraordinarily difficult to separate out what is alcohol induced from what is a separate condition particularly when youíre dealing with an acute patient. Particularly when youíre dealing in a managed care environment where someone tells you you have three days to detoxification the patient and they have to be out the

Methamphetamine abuse has been around for years. Itís just come back again. A very potent stimulant. The major advantage to the user is that itís cheap, it lasts for 24 hours. You can consume it as a crystal, it can be smoked. So it has unfortunate advantages in terms of cost and accessibility over cocaine and some other drugs. So itís become a very major problem. A huge psychiatric problem in terms of psychotic reactions and very severe brain damage that seems to be associated with abuse of this drug. From that point of view, it may well be that thereís a lot more brain damage from cocaine than we are picking up but thatís a subject for another lecture, I guess.

Iíd like to comment now a little bit about opiate use. Most of you probably are not working in settings where you see a lot of heroin addicts. That may change over the next couple of years because the Feds are in the process of rewriting the methadone regulations. Theyíre committed to move in the direction of what they call office based treatment which basically means that for younger addicts or healthier addicts, the more middle class, less psychopathic addicts, they want to get them out of the methadone clinics and get them into other treatment settings and certainly one of those settings may well be your private office and I donít know if youíre ready yet but I think itís coming down the road.

I think weíre moving in the direction of a model that will often have people begin perhaps in methadone treatment programs but if they do well in that setting for two or three years trying to shift them into a private office setting. That shift will probably involve switching to drugs like LAM and buprenorphine which weíll talk about in a second.

Approach for managing opiate withdrawal, here, very clearly, having withdrawal scales, tracking vital signs, beginning with the patient who starts out mistrusting the physician. But I think one trick in managing these patients beyond the pharmacology is that most opiate addicts arenít stupid and most opiate addicts know that most hospitals and most physicians donít like them. They begin treatment

Buprenorphine is a partial opiate agonist. Itís probably going to be approved by the FDA sometime in the next six months. I said that same thing last year but Iím a little bit more confident that theyíre almost there. Buprenorphine has the advantage of a sort of window effect. The higher the dose beyond that window you get no more opiate effect so you canít kill yourself with buprenorphine.

Most addicts when theyíre stabilized on buprenorphine literally feel normal. They feel more normal than they do on methadone. Now for some addicts thatís highly desirable and itís a good, positive step in their addiction recovery. For other addicts, particularly just coming from the street, they donít want to feel normal and I think you have to sometimes respect their ambivalence and the state that theyíre in and often methadone may be a better choice for addicts just getting into treatment because theyíre more aware of an active opiate effect and I think it makes them feel safer and certainly more comfortable.

Iíve included a little bit more detailed information on drugs that interact with methadone. Nowadays since I think there are a lot more of you in general practice who may have AIDS patients, you might have patients who are being treated for depression thatís related to their AIDS who may also be on methadone, you need to be aware of some of the interactions of these drugs. Itís unfortunately getting more complicated, interactions both with AIDS drugs and antidepressants.

No one in the course has talked about Ambien or the use of that drug for sleep. Ambien appears to be less addictive than the benzodiazepines. I think though the last report that Iíve seen suggests that thereís an old story in play here and that is that we come up with a new sedative hypnotic. It doesnít look like it causes addiction and it gets marketed as a very safe drug and then ten years down the road we begin to notice that people are accumulating scenarios of individuals who got addicted to it.

Thatís happening with Ambien. I have no idea what percentage of patients really are vulnerable to abusing that drug. I suspect itís relatively small but I donít think at this point, certainly within the context of substance abuse treatment if youíre looking to find drugs that you can use to deal with sleep problems Iíd suggest nefazodone or trazodone. People will not abuse them and thereís no reason to get yourself in another problem.