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14 - Pharmacotherapy of alcohol misuse, dependence and withdrawal
- from Part III - Specific treatments
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- By George A. Kenna, Center for Alcohol and Addiction Studies Brown University Providence, RI USA, Kostas Agath, Westminster Substance Misuse Services London UK, Robert Swift, Center for Alcohol and Addiction Studies Brown University Medical School Providence, RI USA
- Edited by Peter Tyrer, Imperial College of Science, Technology and Medicine, London, Kenneth R. Silk, University of Michigan, Ann Arbor
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- Book:
- Cambridge Textbook of Effective Treatments in Psychiatry
- Published online:
- 12 May 2010
- Print publication:
- 24 January 2008, pp 289-313
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- Chapter
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Summary
Editor's note
While there is a large volume of research on alcohol misuse, dependence and withdrawal, the pharmacologic solutions are not as directly evident as this amount may suggest. There are widespread cultural determinants as to what constitutes alcohol misuse though the definitions for dependence are much clearer. Yet we do not have good solid pharmacologic treatments to prevent or decrease alcohol usage in the alcohol-dependent individual, though results from the recent COMBINE study suggest a more prominent and effective role for naltrexone in conjunction with medical management. Acamprosate did not fare as well in this trial even though it has been approved for alcohol dependence, and questions of heterogeneity among patient populations might explain conflicting findings. The effectiveness of disulfiram appears to rely heavily upon the patient's determination to remain abstinent. Anticonvulsants may have a role here, but more data is needed. Benzodiazepines remain the gold standard for treatment of symptoms of alcohol withdrawal, while a number of studies also support the use of some anticonvulsant drugs in assisting with withdrawal, especially in cases of mild-to-moderate severity.
Introduction
There is a large volume of research on the pharmacological treatments for alcohol misuse, dependence and withdrawal. Part of that research is marred by methodological difficulties (Moncrieff & Drummond 1997), necessitating increasingly sophisticated means of grading the available evidence to allow generalizability of findings (Mayo-Smith, 1997, Garbutt et al., 1999, Scottish Intercollegiate Guidelines Network –SIGN, 2003, Lingford-Hughes et al., 2004).
19 - Treatment of stimulant dependence
- from Part III - Specific treatments
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- By Mehmet Sofuoglu, Department of Psychiatry Yale University Medical School VA Connecticut Healthcare System Department of Psychiatry West Haven, CT USA, Kostas Agath, Westminster Substance Misuse Services London UK, Thomas R. Kosten, Department of Psychiatry Baylor College of Medicine Houston, TX USA
- Edited by Peter Tyrer, Imperial College of Science, Technology and Medicine, London, Kenneth R. Silk, University of Michigan, Ann Arbor
-
- Book:
- Cambridge Textbook of Effective Treatments in Psychiatry
- Published online:
- 12 May 2010
- Print publication:
- 24 January 2008, pp 369-380
-
- Chapter
- Export citation
-
Summary
Editor's note
Cocaine, amphetamine and methamphetamine are the stimulants considered in this chapter. Yet most of the treatments discussed primarily deal with issues related to cocaine. Despite a growing knowledge base as to the underlying action of stimulants, we have not found psychopharmacologic treatments that consistently can be counted upon to be effective in the treatment of the misuse of substances within this class. There are single randomized control trials that show effectiveness for fluoxetine, imipramine, disulfiram, some dopamine agents and adrenergic blocking agents, but there are few RCT replications of the effectiveness of these agents. The treatment of stimulant abuse remains primarily psychosocial, especially treatments that use a cognitive-behavioral approach, an approach whose effectiveness can be further enhanced with contingency management and the use of vouchers. There is some growing interest and studies of combined cognitive behavioral approaches with pharmacotherapy, but even here no single pharmacotherapeutic agent or class of agents stands out. The measures of effectiveness are usually (a) the presence of drug-free urines and (b) the continued involvement in the treatment program which is referred to as treatment retention.
Introduction
Cocaine and amphetamine addictions have become major public health concerns for over 20 years worldwide. The estimated annual prevalence of cocaine abusers in the population over 15 years of age is 0.3% globally, 0.4% in Europe and 1.7% in the Americas, while the relevant figures for amphetamine abusers are 0.6% globally, 0.7% in Europe and 0.7% in the Americas (United Nations Office for Drug Control and Crime Prevention, 2000).