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I. Extent of Problem

A. Current Magnitude

Nicotine – approximately 50 million addicts
Alcohol – 12 to 18 million alcoholics/problem drinkers
Marijuana – greater than 5 million use at least weekly
Cocaine – over 2 million addicts (perhaps as many as 3½ million)
Heroin – 810,000 addicts, at least

B. Trends

Nicotine – adult use stable, adolescent use continues to rise
Alcohol - use stable with some increase in binge use
Marijuana – sharp decrease in adolescent use from ‘80-‘92’;
sharp increase ‘92-97. 1998 stable to declining.
Use about 2/3’s of where it was in 1980.
Cocaine – 50% decline in non-addictive use since 1985. New initiates to crack decreasing but number of addicts stable.
Heroin – rising use over past decade as purity sharply increases and price drops. Increase in non-injecting use (snorting, smoking)

A. Treatment is not a liberal or conservative approach but a cost effective one

B. Treatment Efficacy

FDA generally considers a 30% improvement in target symptoms sufficient for proving clinical efficacy of a pharmacotherapy

With addiction, however, both lay & professional persons often expect the “smallpox vaccine’ –lifetime immunity after a single dose

More realistic expectations after any one treatment episode

Reduced use of drugs/alcohol

Longer abstention periods

Decreased psychiatric symptoms

Improved health

Maintaining or getting employment

Improved family relations

Decreased criminal behavior

C. Why Treatment?

In addition to being good for the addict, it is good for the rest of society
Not providing treatment for addicts may punish them
But it punishes the non-addicted members of society even more
Addiction impacts on crime, health care, AIDS, welfare, and family and community disintegration

D. Skepticism About Treatment Effectiveness

Skepticism arises from misunderstandings about:
-improvement vs cure
-rehabilitation vs habilitation
-chronic relapsing nature of the condition
-the visibility of failures and the anonymity of successes

E. Voluntary vs Involuntary Treatment

A false dichotomy – not competing frameworks but complimentary ones
Involuntary treatment can be about as effective as voluntary
Treatment can be a cost-effective alternative to incarceration
Criminal justice system pressure can improve length of stay and treatment effectiveness
Family, employer and criminal justice system pressure are all ways of “raising the bottom” to bring about earlier treatment

F. There Is No One Effective Treatment

-Need patient-treatment matching
-Anyone who says they have the treatment for substance abuse is lying – either to you, to themselves or both

“Cure” of withdrawal or overdose

To increase the holding power of outpatient treatment and thus reduce costs

To create a “window of opportunity” during which patients can receive psycho- social intervention to decrease the risk

To serve as long-term maintenance agents for patients who can’t function without them, but can lead productive lives with them.

Agonists
Antagonists
Anti-withdrawal
Anti-craving
Treatment of co-morbid disorders

A. Opiate Addiction

Agonists: Methadone
LAAM
Partial Agonists: Buprenorphine
Antagonists: Naltrexone
Anti-Withdrawal: Methadone; Buprenorphine;
Clonidine; rapid detox using buprenorphine, naltrexone and
clonidine
Anti-Craving: Clonidine or lofexidine

B. Cocaine

Agonists – none yet
Antagonists - none yet
Antiwithdrawal – not a major problem
Anti-craving – none yet; over 30 drugs tried
Vaccine – none yet
Agents to reverse toxic reactions – none yet

C. Alcohol

Agonists – none yet
Antagonists – Disulfiram (Antabuse)
Anti-withdrawal –benzodiazepines
anti-convulsants (Carbamazepine
Valproic acid)
Anti-craving – Naltrexone (Revia)
Acamprosate

D. Nicotine

Agonists – nicotine substitution (gum, patch, aerosol)
Antagonists – mecamylamine
Anti-withdrawal – nicotine substitution
Bupropion (Zyban)
Anti-craving – Bupropion

Unipolar depression
Bipolar disorders
Anxiety disorders
ADHD
Schizophrenia

Treating Comorbid Psychiatric Disorders

Untreated depression and anxiety disorders are common causes of relapse

Withholding psychiatric treatment from a depressed, substance-abusing patient would be like withholding penicillin from a drug abuser with pneumonia

Type of Programs

By Setting

Residential Chemical Dependency Programs (RCD’s)
Residential Therapeutic Communities (T.C.’s)
Outpatient: Intensive, Non-intensive

By Approach

12-step
Supportive
Behavioral (including Relapse Prevention Training)
Psychodynamic

• Treatment can work
• No one treatment is universally effective or “best”
• Variety of approaches needed because of heterogeneity of population
• Careful assessment is important first step