2009-12-30 Nih Basis for Treatment
Transcript of 2009-12-30 Nih Basis for Treatment
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NIH - National Institutes On Drug Abuse (NIDA)
Basis for Effective Treatment
http://www.drugabuse.gov/ResearchReports/methamph/methamph3.html#long
Scientific research since the mid-1970s shows that treatment can help many people change
destructive behaviors, avoid relapse, and successfully remove themselves from a life of substance
abuse and addiction. Recovery from drug addiction is a long-term process and frequently requires
multiple episodes of treatment. Based on this research, key principles have been identified
that should form the basis of any effective treatment program:
1. No single treatment is appropriate for all individuals.
2. Treatment needs to be readily available.
3. Effective treatment attends to multiple needs of the individual, not just his or her
drug addiction.
4. An individuals treatment and services plan must be assessed often and modified to meet the
persons changing needs.
5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
6. Counseling and other behavioral therapies are critical components of virtually all
effective treatments for addiction.
7. For certain types of disorders, medications are an important element of treatment, especiallywhen combined with counseling and other behavioral therapies.
8. Addicted or drug-abusing individuals with coexisting mental disorders should have
both disorders treated in an integrated way.
9. Medical management of withdrawal syndrome is only the first stage of addiction treatment
and by itself does little to change long-term drug use.
10.Treatment does not need to be voluntary to be effective.
11.Possible drug use during treatment must be monitored continuously.
12.Treatment programs should provide assessment for hiv/aids, hepatitis b and c, tuberculosis,
and other infectious diseases, and should provide counseling to help patients modify or
change behaviors that place themselves or others at risk of infection.
13.As is the case with other chronic, relapsing diseases, recovery from drug addiction can be a
long-term process and typically requires multiple episodes of treatment, including "booster"
sessions and other forms of continuing care.
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CO-OCCURRING DISORDERS AMONG PEOPLE WITH STIMULANT USE DISORDERS
Stimulant users have a surprising number of co- or preexisting disorders that can make
differential diagnosis challenging or complicate treatment. Recently, investigators have
become more interested in the implications of premorbid conditions as potential
indicators of vulnerability to stimulant dependence. Majewska points out the need for
more research to establish the epidemiological relationships between preexisting
neurological deficits resulting from genetic, developmental, traumatic, or neurotoxic
factors and vulnerability to drug addiction. More specifically, preclinical studies and some
surveys seem to indicate that neurological deficits associated with AD/HD,
neuroanatomical abnormalities, lead poisoning, alcoholism, posttraumatic brain lesions,
and posttraumatic stress disorder (PTSD) may be correlated with increased vulnerability
to stimulant addiction.
Identified anxiety, phobias, AD/HD, and antisocial personality disorder typically precedecocaine dependence, whereas alcoholism, depression, and paranoia generally follow
stimulant use. Although the symptoms of stimulant-induced psychosis closely mimic
those of schizophrenia, and heavy use of cocaine/amphetamines may precipitate latent
schizophrenia, the two disorders are not closely correlated.
Differentiating comorbid psychiatric disorders from stimulant-related disorders
can be challenging. Acute or chronic stimulant intoxication can elicit symptoms of
anxiety that are indistinguishable from phobias, obsessive compulsiveness, panic, and
generalized anxiety. Withdrawal from stimulants can cause depression that is
indistinguishable from major depression from other causes (Gold and Miller, 1997). It can
take at least a month of abstinence from all stimulant use to differentiate stimulant-induced dysphoria, depression, paranoia, or anxiety from a true psychiatric disorder.
The prognosis for substance use disorders is worsened by the presence of
other untreated psychiatric disorders (or substance use disorders). Clients with
comorbid psychiatric and drug dependence disorders need to have both treated; the
psychiatric problems usually improve with abstinence. Antidepressant and neuroleptic
medications with low anticholinergic and sedative properties are preferred in order to
avoid another addiction. Sedative-hypnotics and benzodiazepines must be used with
caution in high-risk populations.
MEDICAL CONDITIONS
What Does Methamphetamine Do to the Brain?
Methamphetamine's adverse effects on the brain are clear. In animals,
methamphetamine damages nerve terminals in brain regions containing dopamine and
serotonin, two chemicals essential for normal functioning of the central nervous system.
Similarly, in humans, methamphetamine alters the brain in ways that impair decision-
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making, memory, and motor behaviors, and causes structural and functional deficits in
brain areas associated with depression and anxiety. Dopamine cell death, however, has
not been documented in methamphetamine abusers, which could explain why extended
abstinence allows for some recovery from methamphetamine-induced deficits in
dopamine function (Figure 2). But even though a recent neuroimaging study of
methamphetamine abusers showed partial recovery of brain function in some
regions following protracted abstinence, function in other regions did notdisplay recovery even after two years of abstinence7ndash; suggesting that
long-lasting and even permanent brain changes may result from
methamphetamine abuse.
METHAMPHETAMINE AND HIV
In addition to its harmful effects on the brain, methamphetamine is
inextricably linked with HIV, hepatitis C, and other sexually transmitted
diseases. Its abuse increases the risk of contracting HIV not only through theuse of contaminated injection equipment, but also through increased risky
sexual behaviors and through physiological changes that may favor HIV
transmission. Methamphetamine abuse may also affect HIV disease progression. For
example, clinical studies suggest that current methamphetamine abusers on highly
active antiretroviral therapy may be at greater risk of developing AIDS than non-users,
possibly due to poor medication adherence or interactions between methamphetamine
and HIV medications. Similarly, preliminary studies suggest that interactions between
methamphetamine and HIV itself may lead to more severe consequences for HIV-positive
patients who abuse methamphetamine, including greater brain damage and cognitive
impairment. More research is needed to better understand these interactions.
Is continued drug abuse a voluntary behavior?
The initial decision to take drugs is mostly voluntary. However, when drug abuse takes
over, a person's ability to exert self control can become seriously impaired. Brain
imaging studies from drug-addicted individuals show physical changes in areas of the
brain that are critical to judgment, decisionmaking, learning and memory, and behavior
control.7 Scientists believe that these changes alter the way the brain works, and may
help explain the compulsive and destructive behaviors of addiction.
Why do some people become addicted to drugs, while others do not?
As with any other disease, vulnerability to addiction differs from person to person. In
general, the more risk factors an individual has, the greater the chance that taking drugs
will lead to abuse and addiction. "Protective" factors reduce a person's risk of developing
addiction.
What factors determine if a person will become addicted?
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No single factor determines whether a person will become addicted to drugs. The overall
risk for addiction is impacted by the biological makeup of the individual - it can even be
influenced by gender or ethnicity, his or her developmental stage, and the surrounding
social environment (e.g., conditions at home, at school, and in the neighborhood).
Which biological factors increase risk of addiction?
Scientists estimate that genetic factors account for between 40 and 60 percent of aperson's vulnerability to addiction, including the effects of environment on gene
expression and function. Adolescents and individuals with mental disorders are at greater
risk of drug abuse and addiction than the general population.
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What are the basics of effective addiction treatment?
Research shows that combining treatment medications, where available, with behavioral
therapy is the best way to ensure success for most patients. Treatment approaches must
be tailored to address each patient's drug abuse patterns and drug-related medical,
psychiatric, and social problems.
How can medications help treat drug addiction?
Different types of medications may be useful at different stages of treatment to help a
patient stop abusing drugs, stay in treatment, and avoid relapse.
Treating Withdrawal. When patients first stop abusing drugs, they can
experience a variety of physical and emotional symptoms, including depression,
anxiety, and other mood disorders; restlessness; and sleeplessness. Certain
treatment medications are designed to reduce these symptoms, which makes it
easier to stop the abuse.
Staying in Treatment. Some treatment medications are used to help the brain
adapt gradually to the absence of the abused drug. These medications act slowly
to stave off drug cravings, and have a calming effect on body systems. They can
help patients focus on counseling and other psychotherapies related to their drug
treatment.
Preventing Relapse. Science has taught us that stress, cues linked to the drug
experience (e.g., people, places, things, moods), and exposure to drugs are the
most common triggers for relapse. Medications are being developed to interfere
with these triggers to help patients sustain recovery.
How do behavioral therapies treat drug addiction?
Behavioral treatments help engage people in drug abuse treatment, modifying their
attitudes and behaviors related to drug abuse and increasing their life skills to handle
stressful circumstances and environmental cues that may trigger intense craving for
drugs and prompt another cycle of compulsive abuse. Moreover, behavioral therapies
can enhance the effectiveness of medications and help people remain in treatment
longer.
How do the best treatment programs help patients recover from the pervasive
effects of addiction?
Getting an addicted person to stop abusing drugs is just one part of a long and complexrecovery process. When people enter treatment, addiction has often taken over their
lives. The compulsion to get drugs, take drugs, and experience the effects of drugs has
dominated their every waking moment, and drug abuse has taken the place of all the
things they used to enjoy doing. It has disrupted how they function in their family lives,
at work, and in the community, and has made them more likely to suffer from other
serious illnesses. Because addiction can affect so many aspects of a person's life,
treatment must address the needs of the whole person to be successful. This is why the
best programs incorporate a variety of rehabilitative services into their comprehensive
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treatment regimens. Treatment counselors select from a menu of services for meeting
the individual medical, psychological, social, vocational, and legal needs of their patients
to foster their recovery from addiction.
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The clinician should ensure that a treatment plan is developed cooperatively
with the person seeking treatment, that the plan is followed, and that
treatment expectations are clearly understood. Medical, psychiatric, and social
services should also be available.
Because some problems (such as serious medical or mental illness or criminal
involvement) increase the likelihood of patients dropping out of treatment, intensive
interventions may be required to retain them. After a course of intensive treatment, the
provider should ensure a transition to less intensive continuing care to support and
monitor individuals in their ongoing recovery.