Key Concepts

Virtually all abused substances appear to activate the same brain reward pathway

® While activation of the reward pathways explains the pleasurable sensations associated with acute substance use, chronic use of abused substances, resulting in both addiction and withdrawal, may be related to neuroadaptive effects occurring within the brain.

Individuals with a pattern of chronic use of commonly abused substances should be assessed to determine if they meet the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) criteria for substance dependence (addiction).

The treatment goals for acute intoxication of ethanol, cocaine/amphetantines, and opioids include (a) management of psychological manifestations of intoxication, such as aggression, hostility, or psychosis and (b) management of medical manifestations of intoxication, such as respiratory depression, hyperthermia, hypertension, cardiac arrhythmias, or stroke.

O The treatment goals for withdrawal from ethanol, cocaine/amphetamines, and opioids include (a) a determination if pharmacologic treatment of withdrawal symptoms is necessary, (b) management of medical manifestations of withdrawal, such as hypertension, seizures, arthralgias, and nausea, and (c) referral to the appropriate program for substance abuse treatment.

To facilitate recovery from addiction it is necessary to utilize a comprehensive biopsychosocial assessment that includes the motivation for change. Pharmacologic treatments are always adjunctive to psychosocial therapy.

O While pharmacologic agents may help prevent relapse, psychotherapy should be the core therapeutic intervention. Motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), 12-step facilitation (TSF), behavioral couples therapy (BCT), community reinforcement approaches, and contingency management are the best-studied forms of psychotherapy in this group of patients.

Certain pharmacologic agents have been helpful in the treatment of withdrawal and drug maintenance programs.

O A major component of successful treatment of addiction is to continue monitoring the use of medications designed to decrease craving or to block the hedonic effects of abused substances, such as disulfiram, naltrexone, or acamprosate. Also, it is important to identify a mechanism for long-term support of sobriety that might be appropriate for a specific individual, such as Alcoholics Anonymous (AA), a spiritual group, or professional recovery programs for professionals, such as doctors, nurses, police officers, or other professionals.

Substance abuse and dependence are highly prevalent problems in the United States and in the world. In the United States, the use of all substances of abuse has undergone a series of periodic cycles of societal tolerance or condemnation. As an example, cocaine was first isolated from coca leaves in 1860 by a chemistry graduate student in Germany. Its use was advocated by many in the medical establishment until around the mid-1890s when it became evident that chronic use of cocaine might be addictive in some individuals and could be associated with deleterious physiologic effects. Its use decreased following restriction of prescribing and dispensing of cocaine in the early 20th century. Cocaine continued to be abused by a small segment of the population, but much of the medical community seemed to forget the earlier cocaine epidemic. By the late 1970s, at least one pharmacology textbook indicated that cocaine was not addicting. Unfortunately, in the 1980s, a smokeable formulation of cocaine (crack) became available, and cocaine use again became an epidemic. The cyclic nature of substance abuse is common to many drugs, including heroin and marijuana, in addition to cocaine.

The abused substances covered in this chapter include: nicotine, alcohol, cocaine, amphetamines, cannabis, and opioids. While many more substances can be and have been abused, these drugs are among the most popular.

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