CHAPTER 33
Pharmacological Interventions for Substance Use Disorders
LEARNING OBJECTIVES
After studying this chapter, students should be able to:
•
33.2: Identify the commonly used pharmacological treatments for alcohol
use disorders
•
33.4: Identify the commonly used pharmacological treatments for cocaine
use disorders
•
33.6: Identify the commonly used pharmacological treatments for tobacco
use disorders
CHAPTER OUTLINE
The Theory Behind Pharmacotherapy of SUDs
Pharmacological Treatment of Alcohol Use Disorders
Pharmaceutical Treatment of the Alcohol Withdrawal Syndrome (AWS)
Pharmacological Treatment of the Alcohol Use Disorders
Pharmacological Treatment of Stimulant Use Disorders
Bupropion
Mirtazapine
Modafinil
Naltrexone
Topiramate
Gamma-Vinyl-GABA (Vigabatrin®)
Immunological Therapies
Pharmacological Interventions for Cocaine Use Disorders
Experimental Pharmacological Interventions for the Cocaine Use Disorders
Pharmacological Treatment of Inhalant Use Disorders
Pharmacological Treatment of Marijuana Use Disorders
Pharmacological Treatment of Opioid Use Disorders
Experimental Methods of Opiate Withdrawal
Opiate Agonist Agents to Treat Opioid Use Disorders
Medications for Opioid Relapse Prevention
Pharmacological Treatment of the Tobacco Use Disorders
Nicotine Replacement Systems
Non-Nicotine Replacement Pharmaceuticals for Smoking Cessation
Experimental Compounds for Smoking Cessation
CHAPTER OVERVIEW
It is the goal of this chapter to provide an overview of the pharmacological treatment of
substance use disorders (SUDs). The use of such medications is a natural outgrowth of the
“disease” model of the addictions—if it is a disease, we medicate it! Unfortunately, the major
pharmaceutical companies do not seem to share this perspective; they do not view the field of
DISCUSSION QUESTIONS
Break-Out Discussion #1:
Should the addictions be treated with pharmaceutical agents? Although he is a physician,
Breggin (2008) has long been a critic of the pharmaceutical industry. For example, he would
indicate that drug companies continue to develop medications based on the idea that
biochemical imbalances cause the problems. He points out that such is an unsupported
hypothesis. It appears to be right, but sometimes the accepted theory is proven to be absolutely
wrong. Can you think of any examples?
Thus, the “biochemical imbalance” is not automatically correct or incorrect, it is just the most
promising theory developed to date. However, nobody knows what a normal neurochemical
balance in the brain actually is, much less how to achieve that balance! In spite of their “we’re
here to help” public image, pharmaceutical companies want to sell you more pharmaceuticals
so that they make a profit (Breggin, 2008). Through media campaigns they attempt to make
physicians and the general public believe that they need pharmaceuticals to deal with life’s
problems. While this is not to dismiss the benefit of certain medications in the treatment of
certain disorders, do we need medications to deal with all of life’s problems? People have found
ways to cope with the problems of living for so many generations before the rise of the
pharmaceutical industry. Why do they suddenly need medications to cope?
There is a rather interesting paradox inherent in the pharmaceutical treatment of an SUD, in
that we attempt to medicate hypothetical chemical imbalances in the brain, the exact nature of
which we do not understand, with pharmaceuticals whose effects also we do not fully
understand. It is important to keep in mind that although marketed as treatments for specific
conditions, the psychopharmaceuticals have a blanket effect on the entire brain and body, not
just the one subsystem that is hypothetically malfunctioning. As a result, other pharmaceutical
agents are also used to treat various forms of mental illness side effects such as drowsiness and
ataxia. Might not we find in the future that psychopharmaceuticals in use today cause lifelong
damage to the brain?
1). When alcohol or illicit drugs are used, the biochemistry of the individual’s entire brain is also
affected, although it might only be observed in one domain of neurological function.
Questions
1. Are treatments using the pharmaceutical agents described above an improvement over the
damage that the drugs of misuse cause to the brain? Why or why not?
2. Imagine that science discovers a compound that will eliminate the individual’s “craving” for
alcohol or another drug with 100% certainty, which is a huge improvement over the current
generation of pharmaceutical supports. Do we, as a society, have the right to force such
treatments on a patient, even if they are effective? Who should be able to decide what
medications an individual receives to help him or her escape from the addiction?
3. Are the SUDs actually medical disorders, behavioral disorders that affect the body,
2
or a legal
problem? Why? What implications does your answer have for how the disorder/problem is
treated?
4. Do you believe that the SUDs should be treated with pharmaceutical agents? Why or why
not?
Break-Out Discussion #2:
Cocaine inoculations: An anti-cocaine vaccine is currently in clinical trials in humans. The
development of such a compound raises some interesting questions about client’s rights to
refuse treatment.
Questions
1. Would you volunteer to take such a vaccine? Why or why not?
2. Could the courts require that an individual with a cocaine use disorder receive such an
inoculation? If they did, and there was an adverse reaction, who would be responsible—the
company that made the vaccine, or the court system?
3. If a person uses cocaine or has a cocaine use disorder, and refuses to have the vaccine
injected into his or her body, and the courts rule that it be injected in any case, could this be
considered a form of mind control? Why or why not?
4. Is the above scenario analogous to an individual with an SUD refusing other types of
treatment? If not, what factors are different in this situation?
REFERENCES
KEY CONCEPTS AND TERMS
Fixed-dosing regimen: A medication regimen in which a specified amount of a medication is
administered on a fixed schedule
Symptom-triggered regimen: A medication regimen which allows for medication dosage to be
adjusted depending on the patient’s symptoms
“Off-label”: The application of a pharmaceutical for a disease or condition that it is not normally
licensed for. The Food and Drug Administration often will not approve an existing medication for
Antidipsotrophic: An obsolete term used to identify compounds that would combat dipsomania,
or chronic alcohol use
Prodrug: Compound that must be biotransformed into another compound to have the desired
effect
Iatrogenic: Literally, induced by a physician. This term is also often applied to conditions that are
side effects of treatment of another disease, such as antibiotic-induced diarrhea where the
antibiotic compound is used to treat a serious infection elsewhere in the body
Neuroadaptation: The process, once called “tolerance,” by which the nervous system adapts to
the constant presence of a foreign compound. This usually involves modification of the receptor
LO/STANDARDS CORRELATION CHART
A-head
LO
Standard—CACREP
The Theory Behind
Pharmacotherapy
of SUDs
33.1: Understand
the theory
behind the use of
pharmacotherapy
for SUDs
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior
Pharmacological
Treatment of
Alcohol Use
Disorders
33.2: Identify the
commonly used
pharmacological
treatments for
alcohol use
disorders
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior
Pharmacological
Treatment of
Stimulant Use
Disorders
33.3: Identify the
commonly used
pharmacological
treatments for
stimulant use
disorders
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior
Pharmacological
Interventions for
Cocaine Use
Disorders
33.4: Identify the
commonly used
pharmacological
treatments for
cocaine use
disorders
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior
Pharmacological
Treatment of
Opioid Use
Disorders
33.5: Identify the
commonly used
pharmacological
treatments for
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
opioid use
disorders
development, functioning, and
behavior
Pharmacological
Treatment of the
Tobacco Use
Disorders
33.6: Identify the
commonly used
pharmacological
treatments for
tobacco use
disorders
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior