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Day Hospitals

DAY HOSPITALS

Geriatric day hospitals have been part of the health care of older adults for many years. The global increase in the number of older adults has combined with fiscal pressures to decrease lengths of stay in acute care facilities and resulted in shortages of long-term care space in most developed countries. Day hospitals are intended to serve as a midpoint between acute care and out-patient rehabilitation, and to not only delay institutionalization but also to improve quality of life and independence in the patients who attend.

First introduced in the United Kingdom in the early 1960s, when long-term care beds were even more limited than at present, day hospitals were designed to provide interdisciplinary assessment and management of chronic health problems for older persons. They were initially developed in association with geriatric inpatient services to allow access to diagnostic facilities, but many are now sited with ease of access for older persons in mind. There are day hospitals in community centers and in shopping malls in some parts of the world. Day hospitals are even known as community rehabilitation centers in some parts of Australia. Several programs in the United States use centralized day programs to provide integrated assessment and therapy for frail older persons (Program for the All-Inclusive Care of Elders, or PACE ). The key feature is the interdisciplinary assessment and management provided. Staffing usually consists of a geriatrician or physician with special training in the care of the elderly, nurses, nurse practitioners, physiotherapists, occupational therapists, social workers, and sometimes a speech pathologist or nutritionist. Often there is a recreational therapist. Case management models are usually used and day hospitals work in liaison with other community caregivers, such as home care services.

Patients who attend day hospitals benefit from both the therapy and the company of other peers. Most have individual therapy with specific treatment but will also participate in group activities such as exercise and usually some recreation. Some day hospitals provide more acute assessment and management. Persons usually attend for two days per week, although more often in some cases (PACE), and usually for about four hours each day. The geriatric program often arranges transportation.

Day hospitals should be distinguished from day centers, which do not provide specific therapy. Day centers are designed to maintain function and to provide not only activity and socialization but also respite for caregivers. They do not have the rich staffing of the geriatric day hospitals.

Reasons for attendance at a day hospital

The patients appreciate the interdisciplinary framework of a day hospital, which allows them to return to their own home the same day. The usual reason for admission is a complication of a chronic disease that has lead to a functional disability. A few persons are reluctant to come initially, preferring the security and comfort of their own home, but once they have become used to the staff and other patients, they are equally reluctant to leave! Older persons become deconditioned quickly after a serious illness or prolonged period of functional loss and as a result may have lost a considerable amount of muscle strength. They may be recovering from a stroke, an acute illness, a fractured hip, or have arthritis, or Parkinson's disease. For some reason they have become less independent and need physical therapy, adjustment of medications, and help in arranging their daily activities as efficiently as possible. Hypertension and diabetes are common conditions in day hospital patients. The staff of the day hospital spends much time educating the patients and families about the health problems and usually allows them a leading role in establishing the treatment goals. Once those goals have been met, the person is discharged from the day hospital.

Evidence of effectiveness

There is much controversy as to the effectiveness of day hospitals. A recent systematic review concluded day hospital care to be an effective service for elderly people who need rehabilitation, but it did not have any advantage over other comprehensive care, such as home therapy. It may be more expensive. There is little favorable published evidence from randomized controlled trials.

No difference was shown in the rate of hospitalization or degree of disability for patients who attend day hospitals compared to those who receive home care in either a Finnish or a British day hospital. An earlier Canadian study showed no difference in mortality between GDH and usual specialized geriatric care. Randomized controlled trials of geriatric day hospitals have generally failed to show any benefit in terms of either patient outcomes or cost savings, although those patients with the greater degree of disability have seemed to improve in some trials. These disappointing results may have been due to heterogeneity of physical and mental function in the patients who come to day hospitals or the wrong outcomes may have been measured. There may have been too much of a variation in the health status of the persons admitted to the day hospitals. The measurement instruments may not have been the best ones to measure important changes. Instruments that are designed to discriminate between persons who have a condition and those who do not may not be the best ones to measure change in that condition. If a woman has had a stroke, she may not improve the paralysis of the leg involved by attending the day hospital but after attending she may be able to walk a little further with an aid and feel much better about going out in a car or even public transport. She may also enjoy life more. Measuring her muscle power or the degree of weakness would not have shown much improvement.

On the other hand, it is possible that day hospitals are not effective ways of managing health problems in the frail older adult and other approaches, such as increased home care, need to be better evaluated. There is, however, a high acceptance of this approach from day hospital attendees and staff. Increasing evidence shows targeting patients most likely to benefit may improve outcomes in both physical function and reduction of caregiver stress. In several published studies, patients with the highest degree of physical disability seemed to benefit the most. Better selection of patients in the future may improve the effectiveness of these popular programs, but this would require evaluation in further rigorous research studies.

Irene Turpie

See also Assessment; Frailty; Geriatric Medicine; Health and Long-term Care Program Integration; Multidisciplinary Team; Occupational Therapy; Social Work.

BIBLIOGRAPHY

Brocklehurst, J. C. "Geriatric Services and the Day Hospital." In Textbook of Geriatric Medicine and Gerontology. 2d ed. Edinburgh: Churchill-Livingstone, 1978.

Eng, C.; Pedulla, J.; Eleanor, G. P.; et al. "Program for All-Inclusive Care of Elders (PACE): An Innovative Model of Geriatric Care and Financing." Journal of American Geriatrics Society 45 (1997): 223232.

Forster, A.; Young, J.; and Langhorne, P. "Systematic Review of Day Hospital Care for Elderly People." British Medical Journal 318 (1999): 837841.

Turpiei. "The Geriatric Day Hospital." In The Oxford Textbook of Geriatric Medicine. Edited by J. Grimley Evans. Oxford, U.K. Oxford University Press, 2000. Pps. 10761086.

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treatment

treat·ment / ˈtrētmənt/ • n. the manner in which someone behaves toward or deals with someone or something: the directive required equal treatment for men and women. ∎  medical care given to a patient for an illness or injury: I'm receiving treatment for an injured shoulder. ∎  a session of medical care or the administration of a dose of medicine: the patient was given repeated treatments as required. ∎  the use of a chemical, physical, or biological agent to preserve or give particular properties to something: the treatment of hazardous waste is particularly expensive. ∎  the presentation or discussion of a subject: analysis of the treatment of women in her painting. ∎  (the full treatment) inf. used to indicate that something is done enthusiastically, vigorously, or to an extreme degree: I gave them the full treatment, and they were just falling over themselves.

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Treatment

TREATMENT

The following series of articles provides the reader with brief descriptions of some of the diverse ways that people with substance-related problems can be helped. It is organized into two subsections. Treatment consists of summaries of the common ways that problems relating to specific substances are currently treated. Different approaches are described for alcohol, cocaine, heroin, polydrug abuse, and tobacco. Treatment Types presents descriptions of distinct interventions that are applicable to dependence on a variety of drugs.

In practice, many treatment programs are hybrids, incorporating features from several distinct treatment modalities and adapting them to specific needs having to do with age, gender, ethnic, racial, and socioeconomic factors, provider preference, and the economic realities that govern delivery of treatment.

Neither of the sections is exhaustive. A variety of substance dependence interventions employed in other countries and by certain ethnic groups in the United States (such as sweat lodges among some Native American tribes) are not covered. Nevertheless, the entries included here should allow the reader to become reasonably familiar with what is considered mainstream treatment in the United States at the turn of the millennium.

TREATMENT

This section contains summaries of the common ways that problems relating to specific substances are currently treated. It is organized first by drug and then by treatment approach. Different approaches are described for Alcohol, Cocaine, Heroin, Polydrug Abuse, and Tobacco. The reader should also see the entries for each of these topics and the entries for Barbiturates, Inhalants, and Nicotine under their individual headings, and the section below entitled Treatment Types.

This section contains the following articles:

Alcohol Abuse: 2000 and Beyond ;
Alcohol, An Overview ;
Alcohol, Behavioral Approaches ;
Alcohol, Pharmacotherapy ;
Cocaine, An Overview ;
Cocaine, Behavioral Approaches ;
Cocaine, Pharmacotherapy ;
Drug Abuse: 2000 and Beyond ;
Heroin, Behavioral Approaches ;
Heroin, Pharmacotherapy ;
Marijuana, An Overview ;
Polydrug Abuse, An Overview ;
Polydrug Abuse, Pharmacotherapy ;
Tobacco, An Overview ;
Tobacco, Pharmacotherapy ;
Tobacco, Psychological Approaches ;
Twelve Step Facilitation (TSF).

Alcohol Abuse: 2000 and Beyond

Every day, more than 700,000 people in the United States receive treatment for problems with alcohol use. Treatment can be behavioral therapy, or behavioral therapy in combination with medication. New therapies will likely take advantage of findings from neuroscience about alcohol's effects in the brain and include medications targeted at specific sites in the brain involved in the development of alcohol use problems.

BEHAVIORAL THERAPY AND ALCOHOLISIM TREATMENT

A broad range of psychological therapies currently are used to treat alcoholism. Many of these therapies have been in use for some thirty years. Others are more recent developments. Many older treatments for alcoholism were developed before modern standards of evaluating treatment outcomes were accepted in the alcohol field. Thus, the various approaches to treating alcoholism have different levels of scientific support for the effectiveness. Treatments that have been evaluated include client-treatment matching and professional treatments modeled on the twelve steps of Alcoholics Anonymous. Newer treatments that have been developed and evaluated include brief or minimal intervention, motivation enhancement therapy, and cognitive-behavioral therapy.

Brief or Minimal Intervention.

One in five men and one in ten women who visit their primary care providers are at-risk drinkers or alcohol-dependent. Brief intervention, which is designed to be conducted by health professionals who do not specialize in addictions treatment, can help at-risk drinkers to decrease their risk and to motivate alcohol-dependent patients to enter formal alcoholism treatment. The main elements of brief intervention can be summarized by the acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy. Although research has shown that brief interventions can be effective it has not yet been widely implemented.

Patient-Treatment Matching.

Patient-treatment matching is using a patient's individual characteristics (such as gender, anger level, social functioning, and severity of alcohol dependence) to select an appropriate treatment therapy. A commonly held view in alcoholism treatment is that matching patients to treatments will improve treatment outcome. This view was supported by thirty small-scale research studies conducted during the 1980s that found a variety of matching effects. A large multi-site clinical trial, Matching Alcoholism Treatments to Client Heterogeneity (Project MATCH), was initiated in 1989 to rigorously test the most promising hypothetical matches. Patients were randomly assigned to one of the following three different types of behavioral therapy:

Motivational Enhancement Therapy (MET), a brief intervention using techniques of motivational psychology to encourage individuals to consider their situation and the effect of alcohol on their life, to develop a plan to stop drinking, and to implement the plan.

Cognitive-Behavioral Skills Therapy (CBST) in which alcoholism is viewed as a type of maladaptive, learned, behavioral response to stressful triggers. In CBST, the patient is taught ways to respond to drinking-provoking situations with non-drinking actions. Patients practiced drink-refusal skills, learned to manage negative moods, and learned to cope with urges to drink.

Twelve-step Facilitation Therapy (TSF), which encouraged patients to become involved in Alcoholics Anonymous (AA). In TSF, trained therapists helped patients to find AA sponsors, arranged for regular AA attendance, introduced patients to AA literature and other materials, and helped patients to work the first five of AA's twelve steps. (TSF was designed specifically for Project MATCH. Although grounded in the twelve-Step principles, it was a professionally delivered, individual therapy different from the usual peer-organized AA meetings and was not intended to duplicate or substitute for traditional AA.)

No decisive matches between patients and treatments were found; the three treatments were approximately equal in their efficacy for all patients. Further, treatment in all three approaches resulted in substantial, long-term reductions in drinking and related problems.

Twelve-step Programs.

Professional Treatment based on the twelve steps of AA is the dominant approach to alcoholism treatment in the United States. Higher levels of AA attendance during and following professional treatment are consistently associated with better outcomes, but AA affiliation without professional treatment has not routinely resulted in improvement. Twelve-step approaches also have been found to be more effective than motivational enhancement therapy for individuals whose social networks support drinking.

Medications for Alcoholism Treatment.

One of the major changes in alcoholism treatment is the current and future availability of medications that can improve treatment outcome. Medications that interfere with craving can reduce the likelihood that a recovering alcoholic will suffer a relapse. Two such medications are currently available: naltrexone in the United States and acamprosate in Europe. A third medication, nalmefene, is currently under study.

Naltrexone.

Naltrexone is the first medication approved to help maintain sobriety after detoxification from alcohol since the approval of disulfiram (Antabuse) in 1949. Originally developed for use in treating heroin addicts by reducing their cravings for this drug, naltrexone was observed to reduce alcohol use by heroin addicts. Further research confirmed this observation: naltrexone used in combination with verbal therapy prevented relapse more than standard verbal therapy alone.

Acamprosate.

Acamprosate was developed in Europe. Clinical trials are now underway in the United States to gain approval by the FDA to market acamprosate in the United States. The results of the European clinical trials of acamprosate were very similar to those found in the U.S. with naltrexone; about twice as many people did well with acamprosate as they did with placebo. They also found, as with naltrexone, that the medication is effective only in combination with behavioral therapy.

Nalmefene.

A new opiate antagonistnalmefenehas recently been tested for use in alcoholism treatment. This medication significantly reduced relapse to heavy drinking among recovering alcoholics, decreased the risk of relapse, and produced no significant side effects. In studies in which naltrexone and nalmefene were compared, nalmefene entered the bloodstream more quickly and had a somewhat lower risk of liver toxicity than did naltrexone.

Combined Therapeutic Approaches.

Combining behavioral therapies with pharmacotherapies is likely to be the next important advance in alcoholism treatment. There are several ways in which behavioral and pharmacological therapies could work together: One therapy might continue to function if the other failed; each therapy might increase the effectiveness of the other; or each might act on the same neural circuits. Naltrexone, used in combination with behavioral therapy, has been shown to prevent relapse more than behavioral therapy alone. The effectiveness of combined therapeutic approaches, including approaches which combine both acamprosate and naltrexone, are currently being examined.

BIBLIOGRAPHY

National Institute on Alcohol Abuse and Alcohol-ism. (2000). Tenth special report to the U.S. Congress on alcohol and health. National Institutes of Health Publication No. 00-1583. Bethesda, MD: National Institutes of Health.

National Institute on Alcohol Abuse and Alcohol-ism. (1995). The physicians' guide to helping patients with alcohol problems. NIH Pub. No. 95-3769. Bethesda, MD: National Institutes of Health.

National Institute on Alcohol Abuse and Alcohol-ism. (1999). Alcohol alert no. 43, brief intervention for alcohol problems. Bethesda, MD: National Institutes of Health.

National Institute on Alcohol Abuse and Alcohol-ism. (1997). Alcohol alert no. 36, patient-treatment matching. Bethesda, MD: National Institutes of Health.

Enoch Gordis

Alcohol, An Overview

Alcohol abuse and Alcoholism are serious problems. Alcohol abuse refers to heavy, problematic drinking by nondependent persons, while alcoholism suggests Tolerance, Physical Dependence, and impaired control of drinking. There are an estimated 9 million alcohol-dependent persons and 6 million alcohol abusers in the United States (Williams et al., 1989).

Problems that arise from misuse of alcohol vary widely, but they often include the following areas: financial, legal, family, employment, social, and medical. Medical complications include alcoholic liver disease, gastritis, pancreatitis, organic brain syndrome, and the Fetal Alcohol Syndrome (FAS). It is estimated that more than 100,000 alcohol-related deaths occurred in the United States in 1987 (Centers for Disease Control, 1990). The most common alcohol-related death is a motor vehicle fatality.

Despite the complex nature of alcohol abuse and dependence, research has burgeoned over the past decade and has deepened our understanding of the causes, prevention, and remediation of alcohol abuse and alcoholism. Here, we briefly review assessment of alcohol problems, detoxification, and treatment.

ALCOHOLISM ASSESSMENT

To appropriately assign an individual to treatment, his or her condition must be accurately evaluated. Management of alcoholism may be seen as involving a five-stage sequential process: screening, diagnosis, triage, treatment planning, and treatment-outcome monitoring. Specific procedures exist to help inform clinical decisions at each of these stages (Allen, 1991). Screening tests help determine whether a drinking problem might exist. If this seems likely, formal and more lengthy diagnostic procedures are performed to specify the nature of the problem. If the diagnosis of alcoholism is established, determination of the type of treatment setting and intensity of care needed for detoxifying and treating the patient must be made next. Treatment planning can then be initiated to establish rehabilitation goals and strategies appropriate to the patient. Finally, outcome is monitored to determine if further treatment is needed or if a different treatment approach is advisable.

DETOXIFICATION

When an alcohol-dependent person abruptly stops drinking, physiological symptoms may occur. This cluster of symptoms is termed alcohol withdrawal, and symptoms can range from relatively mild discomfort to life-threatening problems. Mild symptoms include sweating, tachycardia (rapid heartbeat), hypertension, tremors, anorexia, sleeplessness, agitation, and anxiety. More serious consequences involve seizures and, rarely, Delirium Tremens (DTs), characterized by agitation, hyperactivity of the autonomic nervous system, disorientation, confusion, and auditory or visual hallucinations. It has been postulated that as the number of untreated withdrawal episodes increases, the potential for more serious symptoms in subsequent withdrawals may also escalate. This phenomenon is known as kindling (Brown, Anton, Malcolm & Ballenger, 1988).

Treatment of alcohol withdrawal includes both pharmacological and nonpharmacological interventions. It is generally believed that if the withdrawal symptoms are mild to moderate, no medications are needed. Instruments such as the Clinical Institute Withdrawal Assessment Scale (Foy, March & Drinkwater, 1988) have recently been developed to gauge severity of withdrawal symptoms. Nonpharmacological techniques used to treat milder forms of alcohol withdrawal include efforts to reduce anxiety and to provide emotional reassurance. Patients in withdrawal should receive the B vitamin thiamine so as to prevent the occurrence of the WernickeKorsakoff syndrome, a serious neurological complication of alcoholism.

If the symptoms are more severe, however, drugs should be prescribed. The most commonly used medications to treat withdrawal have been Benzodiazepines. The benzodiazepines have been demonstrated in randomized clinical trials to reduce the occurrence of seizures and other serious withdrawal symptoms. They have a wide margin of safety. Side effects, however, include transient memory impairment, drowsiness, lethargy, and motor impairment. Benzodiazepines must be tapered down and then stopped after the patient is no longer suffering from withdrawal because patients can develop dependence on them. In addition, the physiological effects of benzodiazepines are synergistic or additive with those of alcoholhence, it is important that patients not drink while taking them. Other medications to treat withdrawal include beta-adrenergic blockers, alpha-2 adrenergic agonists, calcium channel blockers, and anticonvulsant agents such as carbamazepine; however, the first two categories of drugs do not prevent seizures and, therefore, are less useful than benzodiazepines. Recent research suggests that carbamazepine may be an effective alternative to benzodiazepines, while calcium channel blockers are still in early stages of research.

TREATMENT OPTIONS

After screening, diagnosing, and detoxifying a patient, the clinical staff has numerous options for short- and long-term treatment. While a more detailed review of these interventions can be found in Hester and Miller (1989), the techniques can be categorized as follows:

Alcoholics Anonymous.

Since the 1940s, Alcoholics Anonymous (AA) has been an important component of alcoholism rehabilitation, and many recovered alcoholics are convinced that AA was essential for their recovery. As a means of achieving and maintaining Sobriety, AA consists of regular meetings utilizing fellowship, mutual support for sobriety, open discussions, and a program known as the Twelve Steps. The effectiveness of AA has not been established by randomized clinical trials, largely because the organization was developed outside the scientific mainstream. A well-designed study by Walsh, Hingson, and their colleagues (1991) was, however, done in the setting of an Employee Assistance Program (EAP). Employees seeking or referred for treatment were randomly assigned to inpatient treatment with AA as a component, AA alone, or self-choice of treatment. All three treatment conditions resulted in equal improvement in job performance; however, inpatient treatment did better than AA or self-choice in terms of several aspects of drinking behavior. Inpatient treatment was particularly valuable for those employees who were abusing both alcohol and Cocaine. Other self-help groups that do not use the twelve-step program (e.g., Rational Recovery) also exist.

Minnesota Model.

The Minnesota Model is so named because it originated in several alcoholism programs in Minnesota and is the most common type of inpatient treatment for alcoholism in the United States. It stresses complete abstinence and employs methods such as group and individual therapy, alcohol education, family counseling, and required attendance at AA meetings. The staff in these programs are usually a mixture of professional individuals and recovering alcoholics. The evidence for its effectiveness is limited. The study by Walsh et al. (1991) supports the idea that these programs are effective. Studies on health-care utilization costs before and after treatment for alcoholism also add evidence that these programs are effective. When this general program is used to treat drug problems other than alcoholism, it is often referred to as a chemical-dependency program.

Group Psychotherapy.

Group psychotherapy is widely used in the treatment of alcoholics. The many types of group psychotherapy employ supportive, cognitive, psychoanalytic, or confrontational techniques. Also, group psychotherapy is often used in conjunction with other approaches, such as AA and pharmacologic adjuncts to treatments.

Individual Psychotherapy.

Individual psychotherapy attempts to probe possible underlying reasons for problem drinking and subsequently strives to guide the patient in working through emotional difficulties. Some of the cognitive and behavioral approaches described below can also be considered forms of psychotherapy. Similar to group psychotherapy, individual psychotherapy is often combined with other treatment activities. Despite the widespread use of group and individual psychotherapy, the scientific evidence supporting their efficacy as isolated treatments is limited.

Family and Marital Therapy.

This type of therapy involves the problem drinker, spouse, and sometimes other family members. Over the past several years, research interest has heightened in determining the contribution of family and marital factors in aiding the patient to sustain recovery. Generally, family and marital therapy seeks to enhance communication, problem-solving, and positive reinforcement skills.

Social-Skills Training.

Social-skills training includes techniques for improving communication skills, forming and maintaining interpersonal relationships, resisting peer pressure for drinking, and becoming more assertive. Research on its effectiveness has been encouraging.

Relapse Prevention.

Relapse prevention is a behavioral approach that deals with teaching the patient to successfully cope with environmental situations that may serve as high-risk drinking stimuli. Relapse prevention is important in alcoholism treatment, since many patients who are successfully detoxified and stabilized tend to revert to drinking. While relapse prevention is widely used, the evidence of its effectiveness is again limited, albeit promising.

Stress Management.

Stress-management techniques may be employed to reduce emotional discomfort, which may contribute to drinking behavior. Specific techniques include deep-muscle relaxation, biofeedback, systematic desensitization, and cognitive and behavioral strategies to cope with stress-inducing stimuli.

Pharmacotherapy.

Since the 1950s, Disulfiram (Antabuse) has been the most widely used medication in the treatment of alcoholism. Patients on disulfiram are deterred from drinking because to do so would cause physical discomfort, including headaches, flushing, and rapid heartbeat. A major problem in using disulfiram is lack of patient compliance. Several techniques have been developed to enhance compliance, including establishing a contract with the client or significant other on disulfiram administration, offering positive and negative incentives for taking the medication, and using implants.

In addition to disulfiram, recent advances have been made in the development of medications that directly curb desire to drink. The most promising include serotonergic agents and opioid antagoniststhese agents act on brain mechanisms that are believed to be related directly to drinking.

Aversive Therapy.

This type of therapy attempts to establish a conditioned avoidance response to alcohol. Drinking is paired with unpleasant experiences, such as electric shock, nausea, vomiting, or imagined unpleasant consequences. The underlying rationale of Aversion conditioning is that patients will be less likely to drink if they associated alcohol consumption with immediate negative consequences. Good evidence that this approach is effective is lacking, because of the absence of randomized clinical trials evaluating aversive therapy. Some programs using it report very high levels of abstinence, however, in the months following inhospital treatment.

Patient-Treatment Matching.

A newer strategy in alcoholism treatment attempts to match particular types of treatments to relevant patient characteristics, rather than assigning all patients to similar treatments. Common patient-matching variables include the patient's collateral psychopathology, degree of alcohol involvement, and personality and motivational characteristics. Approximately forty studies, although based on small numbers of patients, have supported the concept that patient-treatment matching improves treatment outcome.

Community-Reinforcement Approach.

The community-reinforcement approach (CRA) is a broad-spectrum treatment approach that focuses on positive reinforcers for abstinence in the patient's natural environment. Specific techniques include adding improvements to the patient's employment conditions, marital relationships, problem-solving skills, social skills, and stress managementand different components of the program are chosen for the individual, depending on his or her life problems. The initial studies of CRA are encouraging.

CONCLUSIONS

Advances in treatment research have led to a variety of treatment interventions. The alcoholism-treatment community must become better able to assist the recovery of alcoholics and alcohol abusers. Advances in assessment technology have helped identify patient needs more clearly; this subsequently enables the clinician to provide a treatment regime tailored to the needs of the patient. An important future direction for alcoholism-treatment research is to discover how to more precisely match patients with specific types of treatment interventions. Also, development of new medications to directly reduce drinking behavior will have a major impact. Future treatments will likely combine pharmacologic interventions with behavioral and psychosocial therapies to further improve treatment outcome.

(See also: Accidents and Injuries from Alcohol ; Complications ; Treatment, History of ; Treatment Types )

BIBLIOGRAPHY

Allen, J. P. (1991). The interrelationship of alcoholism assessment and treatment. Alcohol Health and Research World, 15, 178-185.

Brown, M. E., et al. (1988). Alcohol detoxification and withdrawal seizures: Clinical support for a kindling hypothesis. Biological Psychiatry, 23, 507-514.

Centers for Disease Control. (1990). Alcohol-related mortality and years of potential life lostUnited States, 1987. Morbidity and Mortality Weekly Report, 39 (11), 173-175.

Foy, A., March, S., & Drinkwater, V. (1988). Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcohol: Clinical and Experimental Research, 12 (3), 360-364.

Hester, R.K., &Miller, W.R. (Eds.). (1989). Handbook of alcoholism treatment approaches: Effective alternatives. New York: Pergamon.

Walsh, D. C., et al. (1991). A randomized trial of treatment options for alcohol-abusing workers. New England Journal of Medicine, 325, 775-782.

Williams, G. D., et al. (1989). Epidemiologic Bulletin no. 23: Population projections using DSM-III criteria. Alcohol Health and Research World, 13 (4), 366-370.

Richard K. Fuller

John P. Allen

Raye Z. Litten

Alcohol, Behavioral Approaches

The use of behavioral and other psychological treatments for alcohol abuse has a long history. In the nineteenth century, Benjamin Rush, often regarded as the founder of American psychiatry, described a variety of social and psychological cures for chronic drunkenness. Treatment procedures derived from principles of learning and conditioning were being tested in the 1920s, prior to the development of modern pharmacologic approaches. Currently, there is a large scientific literature documenting the effectiveness of various behavioral treatments for alcohol problems.

The most obvious argument for the use of behavioral approaches in treating alcohol abuse is that the drinking of alcohol or ethyl alcohol is a behavior. Regardless of the therapeutic approach used, the criterion for success or failure in treatment studies is typically behavioralwhether and how much a person continues to drink. Research amply demonstrates that drinking behavior is substantially influenced by a wide variety of psychological processes, including beliefs and Expectancies, the examples of friends and family, the customs and norms for drinking within one's society or subgroup, emotional states, family processes, and the positive and negative consequences of drinking. Treatments that address these factors directly, then, might be expected to be helpful in overcoming alcohol problems.

In fact, dozens of well-controlled studies since the 1960s do support the effectiveness of behavioral treatments. The benefits of such treatment have typically been larger than those reported for pharmacologic approaches and have been shown in some studies to endure over follow-up periods of several years. This research in itself provides a convincing reason to use behavioral methods in treating alcohol abuse.

Still another reason is the finding that psychosocial processes strongly influence whether or not a person will relapse after treatment. The likelihood of relapse is decreased by factors such as marital stability, social support, personal coping skills, employment, and confidence in one's abilities to deal with problems. Factors like these in a person's life after treatment are important determinants of outcome. Treatment methods that anticipate and address these post-treatment adjustment challenges are thus important.

There is, however, little reason to argue for behavioral versus pharmacological treatment approaches, since these two approaches can be used together with good result. Behavioral methods play a key role in addressing psychosocial aspects of drinking problems and are compatible with the use of medications, where they are appropriate.

ALTERNATIVE BEHAVIORAL METHODS

A behavioral approach to treating alcohol abuse does not involve just one method. Rather, a variety of strategies can be used to accomplish the central goalto change drinking behaviorand several methods are typically employed in a treatment program.

Treatment methods should not be confused with treatment goals. The general behavioral methods described below can be applied in pursuit of different goals. Sometimes the goal of treatment is the complete elimination of alcohol drinking for the rest of a person's lifetime (total and permanent abstinence). For others, the goal may be to reduce alcohol use to a level that will no longer threaten a person's physical or psychological health. The goals of treatment may also include other important dimensions besides drinkingto get and hold a job, to have a happier marriage and family life, to learn how to deal with anger, and to find new ways of having fun that do not involve drinking. Finally, it is worth noting that clients may have treatment goals that differ from those of the therapist. Behavioral treatment methods do not inherently dictate outcome goals, but they can be used to achieve goals once chosen.

Teaching New Skills.

Alcohol is often used in an attempt to cope with life problems. People may drink to relax or loosen up, to get to sleep, to feel better, to enhance sexuality, to build courage, or to forget. In truth, alcohol rarely works as an effective coping strategy for dealing with emotional and relationship problems. In the long run, it often makes such problems worse. Yet the seeming immediate relief can make alcohol appealing when a person is faced with bad feelings or social problems. To the extent that a person comes to rely upon drinking to cope, that person is termed psychologically dependent on alcohol.

One behavioral approach, sometimes called broad-spectrum treatment, directly addresses this problem by teaching the person new coping skills. Ten controlled studies, for example, have found that the addition of social-skills training increases the effectiveness of treatment for alcohol abuse. People are taught skills for expressing their feelings appropriately, making requests, refusing drinks, and carrying on rewarding conversations. Stress-management training has also been shown to help prevent relapse to drinking. People learn how to relax and deal with stressful life situations without using drugs.

Self-Control Training.

Another well-documented behavioral approach is self-control training, which teaches methods for managing one's own behavior. Some common elements in self-control training include: (1) setting clear goals for behavior change; (2) keeping records of drinking behavior and urges to drink; (3) rewarding oneself for progress toward goals; (4) making changes in the way one drinks, or in the environment, to support new patterns; (5) discovering high-risk situations where extra caution is required; and (6) learning strategies for coping with high-risk situations. Although often used to help people reduce their drinking to a moderate and nonproblematic level, self-control training can also be used when total abstinence is the goal. This method has been found to be particularly helpful for less severe problem drinkers. It has also been found to be more effective than educational lectures for drunk-driving offenders.

Marital Therapy.

There are several reasons to consider treating not only the excessive drinker, but also the spouse. First, problem drinking commonly affects the drinker's partner in adverse ways. Secondly, the spouse may be quite helpful during treatment in clarifying the problem and in developing effective strategies for change. Thirdly, the spouse can provide continuing support for change after treatment. Finally, marital distress may be a significant factor in problem drinking, and direct treatment of marital problems can help to prevent relapse.

Research indicates that problem drinkers treated together with a spouse fare better than those treated individually. Behavioral marital therapy in particular is well supported by current outcome research.

Aversion Therapies.

Another set of treatment strategies applies the learning principle of aversive counterconditioning (called Aversion Therapy). The idea here is that if drinking is paired with unpleasant images and experiences, the desire for alcohol is diminished, and drinking decreases. There is sound evidence that it is possible to produce a conditioned aversion to alcohol in both animals and humans. The taste and even thought of alcohol become unpleasant. There is also evidence that aversion therapy is successful to the extent that this kind of conditioned aversion is established during treatment. Some forms of aversion therapy pair the taste of alcohol with unpleasant sensations such as nausea, foul odors, or electric shock. A newer form, termed covert sensitization, uses no physical aversion of this kind but instead pairs alcohol with unpleasant experiences in imagination. These approaches may be particularly useful for those who continue to experience craving or a strong positive attachment to alcohol.

Psychotherapy.

Many kinds of psychotherapy have been tried with alcohol abusers. In general, studies suggest that individual psychotherapies with a goal of insight into unconscious causes of drinking have been largely unsuccessful. Likewise, group psychodynamic psychotherapies have had a poor track record in treatment-outcome studies. As a distinct element, confrontational group therapy, a common element of U.S. treatment programs, is also unsupported by current research. More recently, cognitive therapies have gained popularity, and some controlled trials supporting their efficacy.

Changing the Environment.

Yet another behavioral approach is behavior modification by changing the consequences of drinking. The goal here is to eliminate positive reinforcement for drinking, and to make alternatives to drinking more rewarding. Studies have reported success in working unilaterally with a drinker's spouse to make changes that discourage drinking and reinforce alternatives. A complex treatment known as the community-reinforcement approach (CRA) has fared well in comparisons with traditional methods. The CRA systematically encourages rewarding alternatives to drinking, teaching skills needed for living without alcohol. The CRA incorporates a number of treatment elements, including marital therapy, social-skills training, the taking of disulfiram (Antabusea medication that causes aversive effects when alcohol is ingested), and job-finding training. The use of behavioral contracting drawing up a specific agreement about future drinking and its consequenceshas been found to be an effective component of treatment in several studies.

Brief Motivational Counseling.

An interesting and unexpected finding in more than a dozen well-controlled studies is the effectiveness of relatively brief motivational counseling. Certain treatments, consisting of one to three sessions, have been found to be significantly more effective than no treatment and often as effective as more extensive treatment regimens. These motivational approaches, now studied in several nations, typically include a thorough assessment, feedback of findings, clear advice to change, and an emphasis on personal responsibility and optimism. The key seems to be to trigger a decision and commitment to change. Once this motivational hurdle has been crossed, people frequently proceed to change their drinking on their own without further professional assistance. In fact, treatment approaches that proceed directly into strategies for changing drinking may fail because they do not address this motivational prerequisite for change.

Therapist Style.

Other recent research indicates that the skills and style of the therapist have important effects on treatment outcome. With impressive consistency, therapist success has been linked to an empathic and supportive style, rather than an aggressive and confrontational approach. Directive and confrontational tactics tend to elicit resistance and defensiveness from clients, which in turn are predictive of a lack of therapeutic change. It is clear that the same treatment approach can have dramatically different outcomes when administered by different therapists.

HOW IS SUCCESS JUDGED?

In one sense, judging the outcome of treatment would seem simple: Either the person is or is not still drinking in a problematic manner. A closer examination of treatment-outcome research quickly reveals a number of complexities.

First is the question of the standard against which a treatment is to be judged. Is a "success" rate of 60 percent spectacularly good or shameful? This is decided relative to the expected outcome without the same treatment. This is why the usual standard for judging effectiveness in medical research is the controlled trial in which clients are randomly assigned to different treatment methods. In the absence of proper controls, one cannot judge adequately whether the outcome of a treatment is better or worse than it would have been without the special treatment. Evidence from properly controlled trials is more consistent than the results of uncontrolled trials, presenting a clearer picture of effectiveness.

A second complexity is: What constitutes success? When success is defined very conservatively, as total abstinence from alcohol (not even one drink) since the end of treatment, low success rates can be expected. Yet if some drinking is permitted among "successes," it is necessary to define the acceptable limits for how much, how often, and with what consequences. Some studies have reported only a category of "improved" cases without adequate definition.

Once successful outcome is clearly defined, there is the problem of how to measure it. Should a researcher accept the client's self-report? Should friends and family members be interviewed? Should blood, breath, or urine samples be required? If multiple outcome measures are used, how does one decide which is the truth?

Still another example is the issue of length of follow-up. Success rates are typically highest within a few weeks or months from the time of treatment. A large percentage of relapses occur between three and twelve months after treatment. Short follow-up periods, then, overestimate success rates. Longer follow-ups raise the additional problem of how to deal with lost cases. If one studies only those who can be easily found two years later, success rates may be inflated.

For these reasons, the effectiveness of treatment approaches is best judged by accumulating evidence from several properly controlled studies. Conclusions presented above, regarding the efficacy of different psychological treatment approaches, were drawn on this basis.

MATCHING PEOPLE TO TREATMENTS

It is unlikely that research will ever identify a single superior treatment for alcohol abuse. Drinking and alcohol-related problems are far too complex. The cause for real optimism is found in the number of different approaches with reasonable evidence of effectiveness. For a given person, then, the chances of eventually finding an effective approach are good.

Recent research indicates that these various treatment approaches work best for different kinds of people. As such evidence accumulates, it will be increasingly possible to choose optimal treatment strategies for people based on their individual characteristics. Treatment systems, therefore, should work toward providing a range of different approaches, rather than offering the same basic treatment to everyone with alcohol problems.

(See also: Causes of Substance Abuse ; Disease Concept of Alcoholism and Drug Abuse ; Treatment Types )

BIBLIOGRAPHY

Brown, S., & Lewis, V. (1998). The alcoholic family in recovery: A developmental model. New York: Guilford Press.

Cox, W.M. (Ed.). (1987). Treatment and prevention of alcohol problems: A resource manual. Orlando, FL: Academic Press.

Hester, R.K., &Miller, W.R. (Eds.). (1995). Handbook of alcoholism treatment approaches: Effective alternatives, 2nd ed. Needham Heights, MA: Allyn & Bacon.

Milkman, H. B., & Sederer, L.I. (Eds.). (1990). Treatment choices for alcoholism and substance abuse. Lexington, MA: Lexington Books.

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

Monti, P. M., et al. (1989). Treating alcohol dependence. New York: Guilford Press.

Washton, A.M. (Ed.). (1995). Psychotherapy and substance abuse: A practitioner's handbook. New York: Guilford Press.

William R. Miller

Revised by Anne Davidson

Alcohol, Pharmacotherapy

Research on pharmacotherapy for Alcoholism continues to expand, as there are still many questions unanswered at the turn of the millennium. Currently, the most widely used medication for the treatment of alcoholism is Disulfiram, which has been in use for half a century. Disulfiram (Antabuse) does not act to reduce the Craving for Alcohol or ameliorate the euphorigenic (feeling of well-being) effect of alcohol. A variety of newer drugs were tested in the late 1990s but have not fulfilled early expectations. It was hoped that "anticraving" medications and medications that reduce the "high" from drinking alcohol would be particularly useful in recovering alcoholics who are prone to relapse. Medications originally developed to treat Depression and Anxiety were also thought to have potential for managing drinking behavior in specific subgroups of alcoholics. These also do not appear to be helpful except among some alcoholics with comorbid psychiatric disorders.

This article focuses on four categories of medications that are either currently available or are still being tested for the treatment of alcoholism and alcohol abuse. These include the following: alcohol-sensitizing agents; agents that directly attenuate drinking behavior; agents to improve cognition in patients with alcohol-induced impairments; and agents to treat psychiatric problems concurrent with alcoholism. The most promising medications within each of the above categories are examined, addressing their stage of development, clinical efficacy, potential side effects, and future research. The first section of this article will describe briefly the methodology used to conduct clinical pharmacotherapy studies.

CONTROLLED CLINICAL TRIALS

The method used to determine medication efficacy is called the controlled clinical trial. The key components of clinical trials include the following: control groups; random assignments of eligible subjects to medication or to control groups; use of placebos (identically appearing but inactive medications) for the control groupunless a standard effective medication is available to serve as the comparison; assurance that neither the patients receiving the drug nor the physicians administering/prescribing know whether they are getting the active medication or the placebo (called double-blind); methods that validly and reproducibly measure the response to the medication; methods to monitor whether subjects take the medication; and procedures to follow all the patients who entered the study for the duration of the clinical trial. After the data are collected, they must be analyzed by using the appropriate statistical tests.

Randomizing.

It is important to randomize eligible patients to the treatment and placebo groups, because this assures that the two groups are comparable except for the medications being prescribed. If some method other than randomization is used to assign patients to treatments, it is likely that the groups will differ in important characteristics such as severity of illness. If one of the groups is in general more severely ill than the other, the sicker group is less likely to do well regardless of the treatment. If the more severely ill group receives the active medication, the difference between the medication group and the placebo group after treatment does not appear as great because the placebo (control) group was less ill at the beginning. Thus, it may appear that the medication was not effective.

Double-blinding.

"Blinding" of both the patients and the physicians is necessary because of their expectations and beliefs. Patients usually seek treatment in the expectation that the physician will prescribe or recommend something that will cure or improve their condition. Hence, patients who receive placebos often feel better. Therefore, if a placebo control is not used, one might conclude that a new treatment works when one is only observing the placebo kind of response. (Conversely, patients often report side effects when they take placebos. So not all side effects are necessarily due to an active medication.) Physicians often believe very strongly that the new drug will be the effective treatment they are searching for, and their objectivity is diminished by this bias. To remove this influence on their perception of the outcome of treatment, the physicians treating the patients are "blinded" as well as the patients, hence a double-blinding is effected.

Accurate Assessment.

If the methods used to assess the response to treatment do not accurately measure the response to the medication, erroneous conclusions may be drawn (Fuller, Lee, & Gordis, 1988). Patients' self-reports about their response to treatment should not be used without corroborating data in controlled clinical trials unless no other means for obtaining information is available. Such reports may be inaccurate for a variety of reasons, including inaccurate memory and the tendency to give socially desirable answers.

It is also important to know whether the patients actually took the medications. Often, patients do not take their medications or take them erratically, particularly if they are being treated for an asymptomatic condition for a long period of time and/or if the medication has a high incidence of unacceptable side effects (Haynes, Taylor & Sackett, 1979).

Patients who drop out of treatment frequently are atypical of all patients in treatment. In alcoholism treatment, the dropouts are usually drinking and having problems because of their drinking. So, if a study bases its conclusions only on those who stay in treatment, the results of the therapy are likely to be exaggerated. Therefore, it is important to locate and assess treatment response in all or almost all who initially began treatment. For an excellent description of clinical trials, their methods and issues, see Byar et al. (1976).

If control groups were used, methods other than randomization were used to assign patients to the disulfiram group or the control group. Hence, the groups were not comparable, and placebo groups were rarely used. "Blinding" was not done. No attempts were made in most of the studies to determine whether patients took the medication. The alcoholic's report on abstention from alcohol was the only information obtained to judge whether disulfiram was effective. In some studies, only about half the patients were available for follow-up.

Multi-Site Trial.

During the past decade, more rigorously designed clinical trials of disulfiram have been done, and these give more precise information about the efficacy of disulfiram. The largest of these was a multi-site clinical trial done in nine Veterans Administration clinics (Fuller et al., 1986). In this study, 605 men were randomly assigned to three groups:

1) a 250-milligram disulfiram group (the usual dose);

2) a 1-milligram disulfiram group; and

3) a no-disulfiram group.

The 1-milligram group was equivalent to a placebo, because this dose is not sufficient to cause a disulfiramethanol reaction (DER) but controls for the expectation that one will get sick if one drinks alcohol while taking disulfiram. The no-disulfiram group was told they were not receiving Antabuse; it was a control for the standard counseling that alcoholics receive in treatment. The patients in the two disulfiram conditions were "blinded" as to whether they were receiving the 250-milligram or the 1-milligram dose. The data to judge the effect of treatment were collected by research personnel who had no involvement in the treatment of the patients and were "blinded" to group assignment. The research staff members interviewed the patients, cohabiting relatives, and friends (collaterals ) every two months during the year of follow-up. Urine specimens were collected every time the patients returned to the clinic and were analyzed for the presence of alcohol. A vitamin, riboflavin, was incorporated into the 250-milligram and 1-milligram tablets. The nodisulfiram patients received a tablet identical in appearance to the disulfiram tablets but containing only riboflavin. The urine specimens were also analyzed for riboflavin. This allowed the investigators to tell whether the patients were taking their medications regularly.

In contrast to most of the previous studies, this tightly designed study did not find that more of the patients who received disulfiram stayed sober for the year than those who received the placebo or counseling only. Nor was disulfiram associated with better employment or social stability; however, in about 50 percent of the men who relapsed, drinking frequency was significantly less for those who received disulfiram than for those who received either the placebo or no disulfiram. This subset of men who relapsed by drinking less frequently if assigned to disulfiram were slightly older and had more social stability (as indicated by longer residence at their current address) than the other men who relapsed. These results indicate that disulfiram is not more effective than routine treatment for most male alcoholicsfemale alcoholics were not included in the studybut may have some benefit for socially stable male alcoholics.

In the multi-site study, only 20 percent of the patients took the medication regularly; however, abstinence for the year was highly associated with compliance with the disulfiram regimen. This suggests that if ways were found to get patients to take disulfiram regularly, the effectiveness of the drug would be greatly improved. This conclusion has to be tempered by the finding that those who regularly took the 1-milligram placebo or the vitamin without disulfiram, as well as those who took disulfiram, were much more likely to remain sober than those who were less adherent to their regimens. Nevertheless, alcoholism treatment researchers have studied various methods for improving compliance with disulfiram, and preliminary results suggest that these may be beneficial. These treatment strategies have included having the spouse or a treatment facility staff member observe the patient ingesting the medication, establishing a contract with the patient about taking it, and/or building in positive (rewards) or negative (loss of privileges) incentives to take it. A recent controlled study of disulfiram taken in the presence of a relative, friend, or member of the clinic staff found that this method of administration resulted in significantly less alcohol being consumed during a six-month period (Chick et al., 1992). More well-designed studies of these measures to improve compliance with the disulfiram regimen are needed before it is known if they will improve the effectiveness of disulfiram as a treatment for alcohol dependence.

On the basis of the large well-designed studies done to date, it seems prudent to recommend that disulfiram should not be used initially in the treatment for alcoholism. However, if the patient relapses and has indicators of social stability, a discussion with the patient about the possible benefits and the possible risks of disulfiram is warranted, and if the patient is willing to take disulfiram, a trial course is warranted. During the first six months of treatment, it is important that liver tests be monitored closely. The effectiveness of the drug may be enhanced if the patient agrees to take it under supervision.

ALCOHOL-SENSITIZING AGENTS

The most commonly used alcohol-sensitizing agent is disulfiram, which has been used in clinical practice since the 1950s to deter alcoholics from drinking. It is not an aversive drug in the strict sense of the word, since it is not used, as apomorphine is used, to condition individuals to have an aversive response at the sight or smell of alcohol. Rather, its objective is to deter drinking by the threat of having a very unpleasant reaction if one does drink alcoholic beverages. Its severity depends on the amount of alcohol and disulfiram in the blood. The symptoms of the reaction include facial flushing, tachycardia (rapid heart beat), palpitations, dyspnea (indigestion), hypotension (lowered blood pressure), headaches, nausea, and vomiting. Deaths have occurred with severe disulfiramethanol reactions (DERs).

A DER results when alcohol is ingested because disulfiram inhibits the functioning of an enzyme, aldehyde dehydrogenase. This enzyme is needed to convert the acetaldehydethe first metabolic product in the catabolism of ethanolto acetic acid. If aldehyde dehydrogenase is inhibited, an elevation in blood acetaldehyde results. The increased circulating acetaldehyde is believed to cause most of the symptoms and signs of the DER.

Disulfiram is given orally. The usual dose is 250 milligrams, although larger doses have been used. Doses of less than 250 milligrams may fail to cause a DER, while doses of more than 250 milligrams have a greater risk of producing serious side effects. Adverse effects of disulfiram range from mild symptoms such as sedation, lethargy, and a garlic-like or metallic taste in the mouth to more serious side effects such as major depression, psychotic reaction, or idiosyncratic toxic hepatitiswhich may be fatal. A dose between 250 milligrams and 500 milligrams is usually adequate to cause a DER if alcohol is ingested but not so high as to cause major side effects. The dose should be individualized for each patient.

Alcohol-sensitizing agents other than disulfiram also exist. Calcium carbimide, which is available in Canada under the brand name Temposil, has been used clinically, although it is currently not approved by the FDA for use in the United States. Calcium carbimide produces physiological reactions with alcohol similar to those produced by disulfiram, but the onset of action is quickwithin one hour after administrationcompared to twelve with disulfiram. Also, the duration of action is shortapproximately twenty-four hoursversus up to six days with disulfiram. Calcium carbimide, with its faster onset of action, might be especially helpful with impulsive drinkers. A possible side effect of calcium carbimide is reduced thyroid function, however, thus making its use problematic in patients with thyroid problems. It has some additional side effects that include dizziness, slight depression, skin rashes, and impotence. One puzzling side effect of calcium carbimide is a mild elevation in the patient's white blood cell count. As of 2000, there is a paucity of randomized clinical trials comparing calcium carbamide to placeboso, its efficacy is uncertain.

AGENTS THAT ATTENUATE DRINKING BEHAVIOR

The development of medications to curb drinking behavior is one of the important and exciting areas of alcohol research. In developing such medications, researchers have relied on new information about the biological bases of drinking behavior and alcohol craving. This process is complex and involves the interactions among several neurochemical mechanisms, including Neurotransmitters, hormones, neuropeptides, Receptors, second messenger systems, and various ion channels in multiple regions of the brain.

Recent research has focused on medications that alter the functional activity of several neurotransmitter systems. In this section, we discuss medications that directly attenuate drinking by acting on the following neurotransmitter systems: Seroto nin, Opioids, Dopamine, and Gamma-Aminobutyric Acid (GABA).

Agents That Affect the Serotonin System.

Several lines on animal and human research suggest that brain serotonin is associated with alcoholism. Serotonin levels are lower in several regions of the brain in rats selectively bred to drink alcohol than in rats that do not prefer alcohol. In humans, measurements of cerebral spinal fluid levels of 5-hydroxyindoleacetic acid (5-HIAA), a metabolite of serotonin, revealed lower levels of 5-HIAA in alcoholics who were abstinent for four weeks than in nonalcoholics. Also, the availability of the serotonin precursor, tryptophan, appears to be lower in alcoholics, particularly those in early onset of alcoholism (drinking before twenty years of age).

Serotonin-Uptake Inhibitors, commonly used to treat depression, seemed to be effective in reducing alcohol consumption in both animal models and humans. Serotonin-uptake inhibitors act by preventing the uptake of serotonin during synaptic transmission, resulting in a prolonged action. They are easily administered (orally) and require only a single daily dose.

The serotonin-uptake inhibitors available for clinical testing include fluoxetine (Prozac), fluvoxamine, citalopram, and viqualine. Several double-blind, placebo-controlled studies of these agents in various types of subjectsranging from social drinkers to chronic alcoholicsshowed an increase in the number of abstinent days and a decrease in the number of drinks on drinking days (Gorelick, 1989). The effect of the serotonin-uptake inhibitors studied has, however, been modest (a 25% decrease in alcohol intake).

The precise mechanism of action of the serotonin-uptake inhibitors on drinking behavior is unknown. One of the most plausible explanations offered is their ability to suppress appetitive behaviors in general. However, consummatory behaviors are quite complex, and even this hypothesis may be an oversimplification.

In addition to the serotonin-uptake inhibitors, agents that selectively block (antagonists) or activate (agonists) the subtypes of serotonin receptors were considered promising. At least four major types of serotonin (5-hydroxytryptamine, or 5-HT) receptors exist: 5-HT 1, 5-HT 2, 5-HT 3, and 5-HT 4. In turn, 5-HT 1 has several subdivisions, including 5-HT 1A receptor. Research in the early 1990s appeared to indicate that a 5-HT 3 antagonist, ondansetron, reduced alcohol consumption in alcohol abusers (Toneat to et al., 1991). Also, 5-HT 1A and 5-HT 2 receptors were believed to influence alcohol intake. For example, buspirone, a 5-HT 1A agonist and an antianxiety agent, was shown in some studies to reduce alcohol consumption in humans.

Finally serotonergic agents (e.g., fenfluramine) that cause a release of serotonin from presynaptic neurons were tested for clinical efficacy in reducing alcohol intake. In addition, the administration of serotonin precursors was thought to alter drinking behavior. Several animal studies showed that tryptophan (precursor to serotonin) and 5-hydroxtryptophan (hydroxylated form of tryptophan) reduce the amount of alcohol consumed.

As of 2000, however, serotonergic agents have not fulfilled their initial promise. A 1999 review of forty-one major clinical studies of anti-alcohol medications and eleven follow-up studies reported that the data from studies of serotonergic agents were confounded by the high rates of comorbid mood disorders in the subject populations. These medications appear to be useful primarily in the treatment of alcoholics with concurrent psychiatric diagnoses.

Agents That Affect the Dopamine System.

Dopamine is another neurotransmitter identified as influencing drinking behavior. Dopamine is thought to play a major role in the stimulant and reinforcing properties of alcohol as well as other drugs. Decreased levels of dopamine are observed in the Nucleus Accumbens of alcohol-seeking rats (as compared with nonalcohol-seeking rats). The nucleus accumbens is the region of the brain believed to be involved with alcohol craving. Studies in the early 1990s demonstrated that the application of alcohol to the nucleus accumbens and striatum of a rat brain causes a release of dopamine (Wozniak et al., 1991; Yoshimo to et al., 1991).

The administration of medications that increase brain dopamine levels (bromocriptine, GBR 12909, and amphetamine) results in a reduction of alcohol intake in alcohol-preferring rats. Several studies have been conducted in humans using the dopamine type 2 agonist (D 2) bromocriptine. One study (Borg, 1983) indicated that bromocriptine reduced alcohol craving and consumption in severe alcoholics, while another (Dongier et al., 1991) found a reduction in alcohol consumption and an improvement in psychological problems in both bromocriptine-treated and placebo alcoholics, although no significant differences were observed between the two groups.

The efficacy of the dopaminergic medications in the long-term management of alcoholism is currently unclear. Further research needs to be conducted on the two major subtypes of dopamine receptors, D 1 and D 2. In addition, their interaction with other neurotransmitter systems needs to be investigated. An illustration that neurotransmitter systems do not work in isolation and that a medication affecting one may also alter another is present in several studies, which have shown that blocking the serotonin 5-HT 3 receptor with the antagonist ICS 205-930 results in an attenuation of alcohol-induced release of dopamine in the nucleus accumbens and corpus striatum of the rat brain (Wozniak et al., 1990; Yoshimo to et al., 1991).

Agents That Affect the Opioid System.

Studies have shown that the opioid system also plays a role in modifying drinking behavior. Many researchers believe that alcohol craving and increased drinking behavior are related to low brain levels of endogenous opioids (compounds with opium or morphine-like properties, e.g., Endorphins and Enkephalins). Subsequently, increasing the opioid levels causes a decrease in drinking. This is supported by several studies. For example, administration of the opioid agonist [D-Ala 2, MePhe 4, Met (O)5-ol]-enkephalin decreases alcohol consumption in alcohol-preferring mice. Large doses of morphine (a classic opioid agonist) also result in a significant reduction in alcohol intake. In addition, increasing the availability of endogenous enkephalins by injecting mice with the enkephalinase inhibitor kelatorphan (which prevents breakdown of endogenous enkephalins) results in decreased alcohol consumption. Finally, one study demonstrated that high-risk individuals (those who have a family history of alcoholism) have lower plasma levels of beta-endorphin than do low-risk individuals (no family history of alcoholism for at least the three preceding generations).

Some researchers have challenged the hypothesis that excessive drinking is related to decreases in endogenous opioid levels. Experimental evidence includes the observation that low doses of morphine cause an increase in alcohol intake in rats.

Regardless of the mechanism of action, the opioid Antagonists Naltrexone and Naloxonecurrently used to treat opiate abusehave been shown to influence alcohol consumption. Both agents reduce voluntary alcohol intake in rats and monkeys. In humans, studies have shown that alcoholics treated with naltrexone have fewer drinking days, fewer relapses, and less subjective craving for alcohol (Volpicelli et al., 1992; O'Malley et al., 1992). In addition, naltrexone (Trexan) appears to cause few side effects. Interestingly, naltrexone-treated alcoholics who did have one or two drinks were less likely to continue drinking. This is important, since some alcoholics appear to lose control of drinking after one or two drinks.

Naltrexone was the subject of a number of clinical trials in the United States; as of August 2000, ten out of thirty NIH-sponsored clinical trials were studies of naltrexone. However, a review of pharmacotherapeutic agents presented to the National Institute on Alcohol and Alcohol Abuse (NIAAA) in November 1999 concluded that the effectiveness of naltrexone in the treatment of alcoholism appears to be limited. Another review of pharmacotherapy in the treatment of alcoholism published in the Journal of the American Medical Association (1999) noted that naltrexone reduces the relapse rate and the frequency of drinking in alcoholics, but does not substantially enhance the abstinence rate. Studies of a similar compound, nalmefene, yielded the same results.

A secondary drawback to the use of naltrexone in treating alcoholism is the apparent reluctance of many physicians to prescribe it. An NIH study of physicians in three representative states found that very few used it with their patients. The reasons given were the physicians' lack of familiarity with the drug, and its relatively high cost to the patients.

Agents That Affect the GABA System.

Several studies have now investigated the GABA system as a modulator of drinking behavior. The number of GABAergic receptors appears to be greater in the nucleus accumbens region of the brain of alcohol-preferring rats than in those of the alcohol-nonpreferring rats. An anti-craving drug that is presently approved for use in the European Community, acamprosate (calcium acetylhomotaurinate), is thought to inhibit presynaptic GABA (B) receptors in the nucleus accumbens (Berton et al., 1998). A German researcher has noted that this new anti-craving medication has no psychotropic side effects nor any potential for abuse or dependence. Acamprosate lacks hypnotic, anxiolytic, antidepressant, and muscle-relaxant properties (Zieglgaensberger, 1998). Although acamprosate is being used in clinical trials in the United States as of 2000, however, its effects are unclear. It appears to reduce the frequency of drinking, but its effects on enhancing abstinence are no greater than those of naltrexone.

AGENTS TO IMPROVE COGNITIVE FUNCTION

Chronic heavy drinking can lead to impairment of most cognitive functions, including abstract thinking, problem solving, concept shifting, psychomotor performance, and memory. The two most common diseases of cognitive impairment in alcoholism are alcoholic amnestic disorder (Wernicke-Korsakoff syndrome) and alcoholic dementia. Alcoholic amnestic disorder is associated with prolonged and heavy use of alcohol and is characterized by severe memory problems. Though the exact cause is unknown, this disease is thought to be preventable by proper diet, including vitamins, particularly the B vitamin thiamine. The other impairment, alcoholic dementia, has a gradual onset and thus displays various degrees of cognitive impairment, including difficulties in short-term and long-term memory, abstract thinking, intellectual abilities, judgment, and other higher cortical functions.

Most studies indicate that alcoholics with impaired cognitive function will have poorer treatment outcome. This, of course, depends on the severity of impairment. Little research has been conducted with medications to improve cognitive function. Serotonin-uptake inhibitors have shown some promise in improving learning and memory. One study with the serotonin-uptake inhibitor fluvoxamine demonstrated improvement in memory in patients suffering from alcohol amnestic disorder, but not in patients with alcoholic dementia.

AGENTS TO TREAT PSYCHIATRIC DISORDERS CONCOMITANT TO ALCOHOLISM

Alcoholism may be accompanied with various psychiatric problems including anxiety, depression, antisocial behavior, panic disorders, and phobias. Part of the problem in treatment is to determine if the psychiatric disorder developed before alcoholism (primary), or after (as a result of) alcoholism (secondary). Nevertheless, several studies have been conducted predominately with medications used to treat depression and anxiety.

Agents to Treat Alcoholics with Depression.

Depression has been associated with alcoholism, especially with relapse to drinking. A frequent pharmacologic treatment of depression is with a group of medications called tricyclic Antidepressants (desipramine, imipramine, amitriptyline, and doxepin). Their efficacy in treating alcoholics with depression is, however, largely unknown. This is in part because of poor methodological studies. A recent study of desipramine was conducted on alcoholics with and without secondary depression (Mason & Kocsis, 1991). Preliminary findings showed that desipramine is effective in reducing depression in the depressed group and may also prolong the period of abstinence from alcohol in both depressed and nondepressed patients. Preliminary results of another study suggested that imipramine both improves mood and reduces drinking in alcoholics suffering from major (primary) depression.

In addition to the tricyclic antidepressants, the serotonin-uptake inhibitors are used to treat depression. One of these inhibitors, fluoxetine (Prozac), is widely used as an antidepressant. As discussed earlier, fluoxetine has been studied to see whether it attenuates drinking behavior in nondepressed alcoholics, but findings as of 1999 indicate that its usefulness is limited to alcoholics in the dual-diagnosis population.

Lithium, an effective medication for the treatment of manic-depressive disease, has also been studied as a pharmacologic agent in the treatment of alcoholic patients. In one multi-site clinical study of lithium in depressed and nondepressed alcoholics, lithium therapy was not effective in reducing the number of drinking days, improving abstinence, decreasing the number of alcohol-related hospitalizations, or reducing alcoholism dependence (Dorus et al., 1989). This investigation as well as other studies did not address the effectiveness of lithium in other types of psychiatric disorders that may respondincluding hypomania (a mild degree of mania), bipolar manic-depressive illness, and other mood disorders. Studies of lithium in the 1990s concluded that it lacks efficacy in the treatment of alcoholism.

Agents to Treat Alcoholics with Anxiety Disorders.

Recent studies have indicated that a sizeable proportion of individuals who abuse alcohol also suffer from anxiety disorders. Buspirone, an agent commonly used to treat anxiety, has shown potential in reducing alcohol consumption. As discussed earlier, buspirone acts as an agonist on the serotonin 5-HT 1A receptors and also alters the dopamine and norepinephrine systems.

An attractive feature of buspirone is that its use does not lead to physical dependence on the drug, as with antianxiety drugs, particularly with Benzodiazepines. Furthermore, buspirone lacks side effects often found with anxiolytic medications. For example, buspirone lacks sedative, anti-convulsant, and muscle-relaxant properties, does not impair psychomotor, cognitive, or driving skills, and does not potentiate the depressant effects of alcohol.

Administration of buspirone to rats and monkeys has resulted in a decrease in alcohol intake (Litten & Allen, 1991). In humans, one study reported that buspirone diminished alcohol craving and reduced anxiety. Another study found buspirone to be more effective with alcoholics suffering from high anxiety than those with low levels of anxiety. A third study on more severe alcoholic patients found no effect. Thus, further research is needed before this drug's efficacy can be accurately evaluated.

In summary, the evidence indicates that effective treatment of a psychiatric disease may also be beneficial to the treatment of alcoholism, particularly in alcoholics with coexisting psychiatric disorders, but that psychoactive medications are not "magic bullets" for most alcoholics.

CONCLUSIONS

Development of new medications to decrease drinking, prevent relapse, and restore cognition may have a role in alcoholism treatment in the futurebut as a part of treatment regimensgiven with other nonpharmacological therapies. Advances in understanding the mechanisms responsible for alcohol craving, drinking behavior, cognition, and even some of the psychiatric disorders such as depression and anxiety disorders have not yet produced a medication that substantially improves abstinence rates. Some researchers have recommended a careful matching of subgroups of alcoholics to the medications that are presently available as a possible pharmacological treatment strategy.

Moreover, as of 2000, there is much that is still not known about the pharmacological treatment of alcoholism. The 1999 NIAAA report outlined three major areas of inquiry that need further research:

The optimal dosing strategy for anti-alcohol medications and the optimal duration of treatment.

The possible utility of combination therapies, either combinations of different medications or combinations of medication and psychotherapy.

The usefulness of specific pharmacotherapies for women; different ethnic and racial groups; adolescent and geriatric patients; and polydrug abusers.

(See also: Complications ; Disease Concept of Alcoholism and Drug Abuse ; Drug Interactions and Alcohol ; Drug Metabolism ; Treatment, History of )

BIBLIOGRAPHY

Berton, F., et al. (1998). Acamprosate enhances N-methyl-D-apartate receptor-mediated neurotransmission but inhibits presynaptic GABA (B) receptors in nucleus accumbens neurons. Alcohol in Clinical and Experimental Research, 22, 183-191.

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Fuller, R. K., et al. (1986). Disulfiram treatment of alcoholism: A Veterans Administration cooperative study. Journal of the American Medical Association, 256, 1449-1455.

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O'Malley, S. S., et al. (1992). Naltrexone and coping skills therapy for alcohol dependence. Archives of General Psychiatry, 49, 881-887.

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Wozniak, K. M., Pert, A., & Linnoila, M. (1990). Antagonism of 5-HT 3 receptors attenuates the effects of ethanol on extracellular dopamine. European Journal of Pharmacology, 187, 287-289.

Wozniak, K. M., et al. (1991). Focal application of alcohols elevates extracellular dopamine in rat brain: A microdialysis study. Brain Research, 540, 31-40.

Yoshimoto, K., Mc Bride, W. J., Lumeng, L., & Li, T.-K. (1991). Alcohol stimulates the release of dopamine and serotonin in the nucleus accumbens. Alcohol, 9, 17-22.

Zieglgaensberger, W. (1998). Acamprosate, a novel anti-craving compound, acts via glutaminergic pathways. Paper presented at the National Institute on Drug Addiction (NIDA) conference on glutaminergic agents, May 1998. Bethesda, MD: National Institutes of Health.

Richard K. Fuller

Raye Z. Litten

Revised by Rebecca J. Frey

Cocaine, An Overview

Cocaine abuse and dependence should be approached as chronic disorders that require long-term treatment. The clinical course of cocaine addiction is often progressive and generally marked by recidivism. Addiction to cocaine should be approached as a brain disease, and not a weakness to be viewed with judgmental overtones. In fact, cocaine produces a number of neurochemical alterations in the brain, especially in the reward centers of the midbrain and in the limbic system. When evaluating a patient for treatment, many factors must be taken into consideration. First, patients presenting for treatment often have complicating factors, such as coexisting psychiatric disorders, family problems, job jeopardy, and medical complications. These problems are often why the person is seeking treatment, and should be fully explored and linked to the addiction. Interpersonal and occupational dysfunction often results from cocaine becoming the addict's number one priority, taking precedence over family and financial responsibilities. Medical problems frequently result from cocaine's destructive action on the heart, brain, and kidneys, while co-occurring psychiatric disorders commonly include paranoia, depression, and anxiety. To a great extent, the presence of these disorders depends on the length of time the individual has been using cocaine, the dose of cocaine taken, and the route of administration. As individuals progressively lose control over cocaine intake, they become more likely to experience interpersonal, medical and psychiatric complications.

COCAINE USE PATTERNS

Cocaine may be taken in various ways that differ in speed of onset, in blood levels, and, consequently, in brain levels. Subjective effects are most intense when brain levels of cocaine are rapidly increasing to high concentrations. Routes of administration, in ascending order of efficiency, are chewing Coca leaves (absorption through the mucous membranes of the mouth), oral ingestion of cocaine hydrochloride, intranasal absorption of cocaine hydrochloride, smoking of alkaloidal (Freebase) cocaine (Crack), and intravenous injection of cocaine hydrochloride. The use of crack is actually the most rapid delivery of cocaine to the brain, and generally preferred over intravenous use.

There are also different use patterns. Some patients rarely use cocaine except at parties and in relatively low doses. Some ethnic and social groups are particularly likely to use cocaine by the intranasal route, a method that achieves lower brain levels than administration via crack (freebase inhalation) or the intravenous route. Women and adolescent users are more likely to use crack, which is inexpensive per unit dose. A vial of crack sufficient to produce a brief, intense period of euphoria averages two to three dollars in some large East Coast cities. Affordability essentially increases the access of this highly addictive drug to our youth, and to all other segments of our population. Many users tend to administer cocaine several times per week in intense bursts, or binges. A binge may last several hours or even several days. In these individuals the binge is usually terminated by exhaustion of supplies or by behavioral, cardiovascular, or neurological side effects. Binges are often perpetuated by the phenomenon of cocaine use producing additional cocaine Craving. It is not typical to see individuals able to maintain low or moderate doses of cocaine when used on a daily basis.

The higher the dose of cocaine reaching the nervous system and the longer the period of use, the more likely that there will be some form of behavioral toxicity. Personality change consisting of irritability, suspiciousness, and paranoia may occur. Psychosis with Hallucinations and persecutory delusions, often associated with the likelihood of violence, is also seen in heavy cocaine users. Auditory hallucinations are the most common, but tactile and gustatory hallucinations are occasionally reported. During the crash period after termination of a binge of cocaine use, there is often Depression. The period of depression is usually brief, but in some patients it can trigger a major affective disorder, which is a psychiatric syndrome requiring Antidepressant medication. Cocaine addicts often report suicidal thoughts, especially during the crash period. For most patients, cocaine Withdrawal consists of several days of gradually decreasing depression and fatigue with episodes of craving for cocaine.

PHASES OF TREATMENT

Treatment can be divided into three phases: (1) achievement of initial abstinence or detoxification; (2) rehabilitation; and (3) aftercare. The treatment of cocaine abuse or dependence should always be thought of in terms of these phases, and the patient and the patient's family should be told to anticipate a period of treatment lasting at least eighteen months and often three years or longer.

Achievement of Initial Abstinence.

Initial abstinence can be difficult to achieve if severe withdrawal symptoms are present, although most patients do not experience the cocaine "crash" because they use irregularly, stopping and restarting cocaine frequently. Although there is a definite cocaine withdrawal syndrome, it has an irregular pattern and does not fit neatly into distinct phases. Careful studies of patients going through cocaine withdrawal reveal an early severe period of dysphoria, depression, fatigue, and sleepiness. Over the ensuing hours and days gradual improvement occurs. There may also be physical signs, such as a bradycardia (slow heart rate) that gradually returns to normal. These withdrawal symptoms may be accompanied by periodic severe craving for cocaine. If a patient is being treated on an outpatient basis, achieving abstinence can be very difficult.

To assist in the achievement of initial abstinence, researchers have attempted to identify medications that might help reverse brain alterations known to result from chronic cocaine exposure. Dopamine, a neurotransmitter involved in natural reward, appears to mediate the "high" associated with cocaine. There is substantial evidence that repeated cocaine use depletes brain dopamine, leading clinical investigators to test dopamine agents in cocaine patients. Bromocriptine stimulates dopamine receptors but is associated with side effects, and has not been proven effective in preventing Relapse. Few clinicians currently recommend its use to treat acute cocaine withdrawal. Another dopaminergic medication, Amantadine, has been researched in an outpatient study to help patients achieve initial abstinence. It is very important to evaluate potential medications for any disorder by using a comparison or control group. Typically a group of patients is randomly assigned to receive either the drug to be tested or a placebo. Patients are given identical-appearing capsules so that neither the patients nor the physicians know who is receiving the test drug and who is getting the placebo. Such a double-blind trial determined a significant advantage for patients randomly assigned to amantadine as compared with the group receiving a placebo. This advantage was found only during the initial two-week phase of treatment, when the goal is achievement of abstinence, and further research is underway at present to evaluate this dopamine agent. Another outpatient study found desipramine to be helpful in achieving early abstinence and maintaining it for six weeks. This was relatively early in the cocaine epidemic, and the patients were all intranasal users. More severely cocaine-dependent patients have generally failed to respond this well to desipramine.

Rehabilitation Phase.

The major emphasis of treatment should be prevention of relapse to compulsive cocaine use. Some clinicians recommend inpatient treatment to establish abstinence and begin rehabilitation in severely addicted patients. Inpatient treatment by itself is never sufficient and must be followed by an outpatient phase of rehabilitative treatment during which time the patient has returned to his or her prior living environment. Outpatient treatment may be especially difficult if the patient lives in a drug environment and is subject to daily cues that trigger cocaine craving. Many clinicians recommend giving all patients an initial trial of outpatient treatment, reserving inpatient treatment only for those who repeatedly fail in less expensive outpatient programs. This approach is generally embraced by managed care organizations. In many areas of the country, access to inpatient treatment is only available for cocaine addicts with serious medical or psychiatric conditions.

Although the effectiveness of inpatient versus outpatient treatment is pertinent to millions of afflicted individuals, there has been surprisingly little actual research in this area. One study made a direct comparison between outpatient and inpatient rehabilitation. Patients at the Philadelphia Veterans Administration Medical Center were randomly assigned to either an 18-day inpatient rehabilitation treatment or outpatient rehabilitation that included a hospital day program. The hospital day program was similar to the inpatient rehabilitation program and based on the Twelve Steps with emphasis on group therapy and peer support. Some individual therapy was provided for both groups. Patients came to the day hospital five days per week for more than five hours of therapy per day, and returned home in the evening. Those in the inpatient program remained in treatment seven days per week, twenty-four hours per day. At the end of the twenty-eight-day program, both groups were encouraged to continue treatment in an after-care program consisting of weekly visits to the out-patient clinic. At the end of four months and at the end of seven months, evaluations were conducted on all patients initialing the study, even if they had dropped out immediately after beginning. The results showed that there were fewer dropouts in the inpatient program, but there was no significant difference between the two groups. Both had a 50 to 60 percent success rate at the two follow-up periods. Success was defined as no cocaine use for the prior thirty days, supported by a negative urine test at the time of the interview. This study has been cited as supporting the use of less expensive outpatient treatments for cocaine addicts.

Although some individuals are able to stop cocaine use and remain permanently abstinent, most experience slips to cocaine or other drugs. A slip does not necessarily denote relapse or treatment failure, provided the patient is willing to resume counseling and is interested in preventing subsequent use. Slips often occur when patients deviate from treatment recommendations, and treatment compliance can be reestablished in their aftermath. However, slips may turn into "runs" of heavier and heavier cocaine use, resulting in a decision to drop out of treatment and return to active addiction. This is the danger of a slip, and the basis of recommending total abstinence. The use of other addictive agents, such as Opiates, Alcohol, Sedatives and Marijuana, should also constitute a slip. Although clinicians have recognized the need for abstinence from all addictive substances when treating cocaine patients, it has only recently been demonstrated in a research study that the use of alcohol leads to significantly lower recovery rates.

Based on knowledge of the pharmacological effects of cocaine, there has been an intensive search for medications that serve as effective adjuncts in the rehabilitative phase. Cocaine is known to block the dopamine transporter, a specialized membrane protein that clears cocaine from the synaptic space after it has been released, thus helping to terminate neurotransmission. Cocaine use consequently produces excessive dopaminergic stimulation, contributing to the pleasurable effects of the drug. Cocaine also increases the availability of other neurotransmitters, such as serotonin, norepinephrine, and glutamate. The search for a medication to improve the results of cocaine treatment has focused largely on substances that influence dopamine mechanisms, either presynaptic or at the receptor level, and medications that influence brain systems utilizing GABA, glutamate, and serotonin.

Unfortunately, the results of medication research have been disappointing. Desipramine was initially reported to be of some benefit in this phase of treatment, but subsequent studies involving severe cocaine dependence failed to replicate early reports of success. Carbamazepine was proposed as a treatment based on its ability to block the development of subcortical seizure activity produced by cocaine. Controlled studies, however, have failed to show any benefit for this anticonvulsant medication in prevention of relapse. Bromocriptine was not found to improve recovery rates when used in a relatively high dose, perhaps due to study dropouts motivated by excessive side effects. There have been claims of benefit for acupuncture, but there is no scientific evidence to support is efficacy in cocaine dependence. There have also been unsubstantiated reports in the lay literature that the hallucinogenic drug Ibogaine produces a long-term loss of craving for cocaine. The lay press has reported three deaths from the use of this drug and animal studies report neuronal toxicity after ibogaine administration. Baclofen, a drug that indirectly affects dopamine neurons through GABA systems in the brain, may be effective against cocaine craving for theoretical reasons, and is currently under investigation.

Psychotherapy during Rehabilitation.

In addition to standard treatments provided in most rehabilitation programs, such as the twelve-step program, group and family therapy, there have been studies using specific manual-driven psychotherapy and behavioral therapy. A recent report of a large-scale multi-center study demonstrated superior results with individual drug counseling. Furthermore, the effectiveness of individual drug counseling correlated highly with attendance in twelve-step group meetings.

Reinforcement of Clean Urine.

Another treatment approach that has resulted in significant success is using systematic reinforcement of cocaine abstinence. Researchers arranged for patients to be rewarded with vouchers that could be exchanged for desirable goods, restaurant meals or other constructive purchases when they presented drug-free urine. This treatment approach was accepted well by patients, and the results were significantly better than those for a control group receiving counseling alone. A one-year follow-up of patients previously treated for six months in this manner showed that 71 percent were abstinent during the thirty days prior to the follow-up interview.

A similar study has been conducted with opiate-dependent patients who were using cocaine while enrolled in a methadone program. A program of reinforcement of clean urine using vouchers that could be exchanged for desirable objects produced a significant reduction in cocaine use. The use of vouchers to improve retention in treatment, and enhance recovery rates, is the focus of a large government-sponsored effectiveness study currently underway.

Extinction of Cocaine-Related Cues.

Even highly motivated former cocaine-dependent patients experience craving after the cessation of cocaine use. While they are in a protective hospital environment, addicts often feel confident that they can remain abstinent. However, upon returning to their previous neighborhoods they encounter environmental cues that typically result in excitement and cocaine craving. These cues usually are people, places, and things that had previously been linked to cocaine use. Many patients say they become so conditioned to the effects of cocaine that simply seeing their drug dealer or a vial of cocaine produces a rush long before the drug gets into their body. Cue craving has recently been shown to produce a discernible signature of brain activity with the use of PET scanning. Treatments have been designed to reduce or extinguish these conditioned responses. They consist of repeatedly reviewing drug-related stimuli and learning various coping skills, such as the relaxation response, visual imagery, and mastery techniques. These techniques are used by behavioral therapists to reduce the symptoms of other disorders, such as phobias or obsessive-compulsive disorder. For cocaine dependence, the patient can be taught the techniques by a therapist. Later, the patient can practice the techniques in the clinic by viewing videos of cocaine use. There is now evidence that patients randomly assigned to these behavioral treatments do significantly better in outpatient treatment than control subjects assigned to standard treatment with the same amount of attention.

Aftercare.

After about a month of intense rehabilitation treatment, a patient can graduate to an aftercare program of variable intensity. Sessions may initially be once or twice a week, decreasing gradually to once or twice per month. Urine testing should be continued to monitor drug use. The cocaine metabolite, benzoylecgonine, remains in the urine for several days and can effectively signal the resumption of cocaine use. Patients who admit to a slip or whose urine tests indicate cocaine use should resume intensive counseling. Every attempt should be made to determine why the slip occurred so that it can be avoided in the future. As previously discussed, a slip of this nature should not necessarily be considered indicative of treatment failure, even if it results in a significant binge. It is instead a sign that the patient needs to resume intensive treatment for a chronically relapsing disorder. Most clinicians agree that regular daily attendance in twelve-step groups should supplement professional treatment, at least for the first 90 days of recovery. Thus far, there is no evidence that any medication is helpful in this phase of treatment. Of course, if the patient remains depressed or anxious, or has symptoms of another psychiatric disorder, specific treatment such as antidepressants should be employed.

SUMMARY

Cocaine abuse and dependence represent chronic disorders that require long-term treatment. A brief initial inpatient phase may be necessary, but the major part of treatment consists of' long-term outpatient care. Since cocaine addiction is associated with progressive deterioration in functioning, and can produce dangerous medical and psychiatric complications, aggressive treatment is warranted. Various treatment techniques can be used. Most patients receive group therapy and counseling based on the Twelve Steps developed by Alcoholics Anonymous. Professional psychotherapy may be helpful in selected cases, but data are still preliminary. There are also data showing efficacy for behavioral treatments, such as contingent voucher reinforcement of clean urine and extinction of cue craving produced by cocaine-related stimuli. Still, recovery rates from cocaine dependence are disappointingly low, and treatment approaches are being refined. Cocaine use tends to occur in epidemics, especially when there is little perceived danger of it. We appear to be experiencing a dramatic reduction in cocaine use, perhaps because cocaine is widely perceived as dangerous. Therefore, the most effective means of treating cocaine dependence may ultimately involve education of its risks directed toward individuals not yet caught in its grasp.

BIBLIOGRAPHY

Alterman, A. I., et al. (1992). Amantidine may facilitate detoxification of cocaine addicts. Drug and Alcohol Dependence, 31, 19-29.

Alterman, A. I., & Mc Lellan, A. T. (1993). Inpatient vs. day hospital treatment services for cocaine and alcohol dependence. Journal of Substance Abuse Treatment, 10, 269-275.

Crits-Christoph, P.et al. (1999). Psychosocial treatments for cocaine dependence. Archives of General Psychiatry, 56 (6), 493-502.

Childress, A.R.et al. (1999). Limbic activation during cue-induced cocaine craving. American Journal of Psychiatry, 156 (1), 11-18.

Dackis, C.A.&Gold, M. S. (1985). New concepts in cocaine addiction: the dopamine depletion hypothesis. Neuroscience and Biobehavioral Reviews, 9 (3), 469-77.

Higgins, S. T., et al. (1991). A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry, 148 (9), 1218-1224.

Mc Kay, J.R.et al.. (1999). The relationship of alcohol use to cocaine relapse in cocaine dependent patients in an aftercare study. Journal of Studies on Alcohol, 60 (2), 176-80.

Charles P. O'Brien

Revised by Charles A. Dackis

Cocaine, Behavioral Approaches

No consensus exists about how to treat Cocaine dependence. This statement is particularly alarming given that in 1998 it was estimated that 1.8 million persons in the United States were dependent on cocaine. The abuse of cocaine was first recognized in the medical literature in the late 1800s. Early proposed treatments included various herbal and medical potions, nutritional supplements, hot baths, substitution of Morphine, long stays in sanatoriums, education, and psychotherapy. Systematic evaluation of the effectiveness of these early treatments did not occur.

The goals and focus of behavioral approaches for cocaine dependence vary greatly depending on the beliefs held by the treatment provider regarding the causes of cocaine dependence. The efficacy of the various treatments is only beginning to be evaluated. This article describes the primary behavioral approaches used to treat cocaine and discusses the efficacy of those interventions. Although numerous behaviorally-based interventions are being used as treatments for cocaine dependence, this article is limited to providing an overview and discussion of approaches that have received attention in the scientific literature.

OUTPATIENT VERSUS INPATIENT TREATMENT

Studies suggest that inpatient rehabilitation is not cost-effective in most cases of cocaine dependence. It is also not necessary in most cases because withdrawal from cocaine addiction is not physically dangerous, nor does it cause an incapacitating reaction. However, inpatient treatment may be indicated in some instances of cocaine dependence if the patient (1) fails to make progress or deteriorates during outpatient treatment; (2) has severe medical or psychiatric problems; (3) is physically dependent on other drugs, or (4) has a history of criminal involvement. In general, learning to cope with the multitude of environmental circumstances that have contributed to the initiation and maintenance of cocaine abuse is the most important task of the abuser. This task can be accomplished effectively only outside the hospital.

Therapeutic communities, or residential programs with planned lengths of stay of six to twelve months, focus on the resocialization of the individual to society. Resocialization programs at such communities may include vocational rehabilitation and other supportive services. One study has shown that improved cocaine relapse rates for patients with medium- to high-level problems were dependent on longer treatment stays.

COCAINE ANONYMOUS

Cocaine Anonymous (CA) is a community-based self-help group organization modeled after Alcoholics Anonymous (AA). The basic principles are the same as AA's. The program is based on the "disease" model of substance dependence. Achievement and maintenance of abstinence from cocaine is presumed to be facilitated by following the Twelve Steps of CA (which are based on the original Twelve Steps of AA).

CA is available to anyone who expresses a desire to stop using cocaine and all other mind-altering substances. All that is necessary to become a group member is that one attend meetings. Meetings vary from large open ones that anyone can attend to small, closed discussions reserved for specific groups. For example, a group of young people, professionals, or women is organized to address specific concerns. At most meetings, experiences are shared and advice and support are given. Two other components of the CA program are sponsorship and education. A sponsor is a person who has been in recovery for a substantial period of time and who is available at any time to provide support and guidance to the person attempting to recover. Education about the "disease" is provided through pamphlets, books, films, and other literature. CA is recommended by many treatment professionals as the treatment for, or as an important adjunct of treatment for, persons with cocaine problems.

GROUP THERAPY

Many professionals suggest that group therapy is an invaluable component of cocaine abuse treatment. Most groups are structured to include persons of different backgrounds and at different stages of recovery (1) to help deal with feelings of uniqueness, (2) to expose those in the early stage of treatment to positive role models, and (3) to help instill hope for success. Those who promote group therapy view peer pressure and support as necessary to overcome ambivalence about abstaining from cocaine. Providing support for others and the development of intimate social interaction (e.g., sharing of feelings) is facilitated and presumed to be therapeutic.

Topics of discussion in group therapy vary depending on the group members and the orientation of the therapist. Topics may include early abstinence issues, guilt resolution, marital conflict, or lifestyle changes. Education about adverse effects of cocaine is often included. Group therapy occurs in outpatient or inpatient settings. It is sometimes used as the sole source of treatment or combined with individual counseling and other treatment components. Researchers have acknowledged a number of possible limitations to group therapy. They include loss of confidentiality for the individual, likelihood of avoidance of group therapy because of social anxiety, and negative peer influences.

Research on the efficacy of group vs. individual therapy alone or in combination continues. A European review of 22 controlled outcome studies regarding comparisons between individual and group psychotherapy treatments in general found that there is no superiority of one treatment over the other. The study noted, however, that group therapy has an economic advantage over individual therapy. Another study has shown that there are no significant differences in demographic, personality, or addiction severity variables or in treatment retention or 9-month outcome between cocaine abusers who choose individual therapy and those who choose group therapy.

SUPPORTIVE-EXPRESSIVE AND INTERPERSONAL PSYCHOTHERAPY

Psychotherapy is usually suggested as a component of cocaine-treatment programs, both inpatient and outpatient. Typically, the therapy is based on psychodynamic theories of substance abuse. This means that intrapersonal factors and underlying personality disturbances are considered causes of cocaine abuse. It is presumed that cocaine is used to cope with painful emotional states, and that issues such as separation-individuation, depression, and dependency must be resolved to maintain abstinence. The therapist tends to adopt an exploratory role that promotes insight into interpersonal and intrapersonal conflict underlying the cocaine dependence. Increased insight is presumed to result in a reduction in the underlying problems, which, in turn, should help promote cocaine abstinence.

The psychotherapeutic approaches for cocaine abusers are generally similar to the approaches for abusers of other drugs, although treatments for Alcoholism and drug abuse have evolved somewhat differently and the models used may conflict at certain points. A great deal of discussion has been generated about these conflicts in combined treatment for alcohol- and drug-dependent patients, but, overall, the literature is positive about the merits of combining approaches.

One common type of psychotherapy for cocaine dependence is supportive or supportive-expressive psychotherapy. This therapy in combination with pharmacotherapy has demonstrated some efficacy in research with Heroin-dependent persons. Initially, supportive psychotherapy focuses on acknowledging the negative consequences of cocaine use, accepting the need to stop using, and helping manage impulsive behavior. The therapist and user explore ways to stay away from other users and high-risk environments. The focus of treatment then shifts to insight-oriented psychotherapy in which the therapist's role is to facilitate the exploration of underlying reasons for the cocaine abuse. Long-term abstinence depends on the degree to which the underlying psychic disturbances are resolved. A study from the 1990s has led some researchers to conclude that low-intensity psychotherapy was ineffective with the majority of their subjects.

Interpersonal psychotherapy (IPT) was originally developed for and found to be effective with Depression and was adapted for opiate addicts and, later, cocaine abusers. This psychotherapy for substance abusers is based on the premise that drug abuse is one way in which an individual attempts to cope with problems in interpersonal functioning. An exploratory stance focuses on interpersonal relationships and the impact of drug abuse on these relationships. In helping the patient stop his or her substance abuse, the practitioner selects the important components of treatment. They may include documenting the adverse effects of the drugs compared with their perceived benefits, identifying the thoughts and behaviors that precede drug use, and developing strategies to deal with drug-related cues and high-risk situations. Only after attaining abstinence are interpersonal difficulties directly addressed, including the roles of drug use in these relationships.

A key strategy with IPT is to develop more productive means for achieving the desired social gratification or tension reduction for which the drug abuse substitutes. In a multiple drug abuser, this substitution may differ markedly for various drugs. For example, the abuser may be using cocaine to reduce social isolation and to "meet exciting new people" but may be abusing alcohol because the cocaine "crash" is reduced by the alcohol. Since only the cocaine, and not the alcohol, is directly related to the social deficit, only the cocaine abuse will directly benefit from interpersonal therapy. In general, the interpersonal impact will be somewhat different for the abuse of licit drugs such as alcohol, illicit drugs such as heroin and cocaine, and drugs such as benzodiazepines. Among cocaine addicts, for example, the licit drugs such as alcohol are often used in response to interpersonal tension, while the illicit drugs such as heroin lead to consequences of increased interpersonal tension, rather than being used in response to tension. In summary, IPT must identify the relationship of each particular drug to the interpersonal setting as either primary association or secondary to other drug effects and as either a tension reliever or inducer.

COGNITIVE AND BEHAVIORAL THERAPY

Behavioral perspectives of cocaine dependence view drug taking as a learned behavior that begins and continues because of the reinforcing effects of the drug. These reinforcing effects are determined, in part, by basic biological events in the brain. This means that, to some extent, most persons are susceptible to becoming dependent because cocaine produces a reaction in the brain that increases the likelihood that drug taking will recur. The other factors that determine whether a person will become dependent on cocaine are environmental factors (e.g., peers, acceptance by others, and no apparent negative consequences). Research has clearly demonstrated that cocaine seeking and use are learned responses that occur regularly under specific conditions (e.g., certain times of day, events, internal states). This outcome translates into treatment that focuses on changing these "using" conditions and creating new conditions that encourage abstinence from cocaine.

Cognitive and behavioral therapy is a behavioral approach to treating cocaine dependence that is often conducted through group therapy. The idea behind the therapy is to make drug use less attractive and to create alternatives to drug use by changing an individual's internal and external environment. Some therapy is modeled on techniques that individuals have used themselves to abstain from using or cut back on cocaine use. The approach attempts to help patients to recognize situations in which they are most likely to use cocaine, to avoid these situations when appropriate, and to cope more effectively with problems and problematic behaviors associated with drug abuse. For example, individuals learn how to cope with boredom, anger, frustration, and depression, and how to handle social pressure to use drugs. Sometimes individuals rehearse social situations in therapy sessions, to better equip them for handling such situations when they encounter them. Individuals are also urged to give up other drugs, especially alcohol, because of its association with promoting cocaine use and its effect on weakening one's resistance to use. The possibility of a lapse is acknowledged in this therapy and ways to deal with temporary lapses in abstinence are covered so that the individual can work to prevent total relapse. Family and friends are also encouraged to join therapy groups as many researchers believe that such support is one of the most effective ways to promote abstinence. Cognitive and behavioral therapy is considered particularly useful because of its compatibility with a range of other treatments patients may receive, such as pharmacotherapy.

A behavioral therapy component that is showing positive results among many cocaine-addicted individuals is contingency management. Contingency management uses a voucher-based system to give positive rewards for staying in treatment and remaining cocaine free. Based on drug-free urine tests, the patients earn points, which can be exchanged for items that encourage healthy living, such as joining a gym or going to a movie and dinner. Some vouchers can also be exchanged for retail goods.

Another contingency-based method that sometimes works is Contingency Management. With this method, the cocaine addict writes a letter that contains a damaging admission of cocaine use. The addict then agrees that the letter can be made public if his or her urine shows up cocaine-positive after testing. Researchers believe that this type of negative incentive may be effective among cocaine users who have something to lose, as in good employment. Such incentive therapies have shown that cocaine use can be influenced by manipulating the consequences of using.

Another behavioral approach focuses on the conditioned stimuli (environmental events) associated with cocaine use and the way those events affect relapse and deter abstinence attempts. This approach focuses intensely on the persons, places, and things that have frequently been paired with cocaine use. Theoretically, things like drug-using friends, paraphernalia, white powder, and places where cocaine is used can produce cravings for cocaine and ultimately result in cocaine use. Therefore, with repeated exposure to those events under conditions where cocaine is not available (i.e., an extinction procedure), the events gradually lose their ability to elicit the cocaine craving and presumably reduce the probability of cocaine use.

One other behavioral approach that has received increasing attention is Relapse Prevention Treatment (RPT), originally formulated for treating alcohol dependence. Relapse Prevention requires specific interventions based on precipitants that have been identified as associated with the risk of returning to abuse of a specific drug. These precipitants, which include negative emotional states, interpersonal conflict, social pressure, and specific drug-related cues, may be quite different for different drugs of abuse. For example, in a methadone-maintained patient, the precipitants for using heroin or cocaine may be closely related to being with particular "friends" and then "getting high." This "getting high" on heroin can be pharmacologically blocked by large doses of Methadone; large methadone doses will not have a similar effect on cocaine use. Self-monitoring is used to identify risk situations for the specific drug, and then coping strategies are developed using rehearsal of coping behaviors such as anger management and social skills. Preventing relapse focuses on ensuring that brief lapses to cocaine use do not become full relapses. A lapse may be seen as a discreet isolated event that is not uncommon in recovery and that does not nullify all progress. Reduction of this Absinence Violation Effect by reframing the concept in this way may work with all drugs of abuse, although in multiple-drug abusers, sequential lapses in each drug must be prevented by carefully emphasizing the importance of abstinence and not giving "permission" for experimenting with isolated use of the various abused drugs.

In the first test of its efficacy with cocaine dependence, relapse prevention was superior to IPT in retaining individuals in treatment and in facilitating greater rates of cocaine abstinence. A second trial of RPT provided additional support for its efficacy. One-year follow-up data showed RPT to be superior to case management in facilitating higher levels of cocaine abstinence. In a study that compared standard group counseling (STND) with individualized relapse prevention (RP), individuals who commited themselves to a goal of absolute abstinence on starting a continuing care program had better cocaine use outcomes in RP than in STND. However, individuals with looser abstinence goals fared better with STND.

Another two behavioral approaches, coping-skills training (CST) and neurobehavioral treatment, have received support as potentially effective treatments. CST is similar to RPT in that it involves teaching specific drug refusal and coping skills important for accessing alternatives to drug use and for coping with events that place the abuser at high risk. One year-long study found that during the first six months of the study individuals who had CST and relapsed used cocaine on significantly fewer days than did the control group using meditation and relaxation as a coping skill. The study was conducted in the context of high-risk situations. Both groups did equally well in the final 6 months.

Neurobehavioral treatment emphasizes many of the elements of RPT and coping-skills training to assist the abuser to abstain from cocaine and avoid relapse. The "neuro" prefix denotes specific treatment focus on difficulties that may arise due to the neurobiological changes that accompany abstinence from cocaine.

MOTIVATIONAL THERAPY

Researchers have noted a high dropout rate in most studies of addiction treatment and that of those who do remain in treatment, most succeed in breaking the habit. As a result of this success among those who remain in treatment, some researchers believe that the commitment to change from addictive behavior is the greatest factor affecting improvement in the cocaine-dependent individual. Motivational therapy takes advantage of this desire for change and is designed to help addicts realize the extent of their problem and help increase their desire to quit. It also prepares them for other treatment. Motivational elements used in such therapy are described by the acronym FRAMES (feedback, responsibility, advice, menu of options, empathy, and self-efficacy).

ECLECTIC TREATMENT

Many treatment providers use an eclectic approach to treat cocaine dependence; that is, a combination of approaches. For example, many programs based on a disease or a psychodynamic model may use certain behavioral procedures such as contingency contracting or relapse prevention strategies.

In a collaborative cocaine treatment study conducted by the National Institute on Drug Abuse, researchers found that group drug therapy plus individual drug counseling was more effective than cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone.

In general, a limitation of eclectic approaches is that mixed messages may be given to the patient. Moreover, the intensity and quality of each component may not be as high as approaches that are more unilateral in focus. For example, behavioral approaches spend a great deal of time counseling and assisting the abuser to make the behavioral changes needed to achieve and maintain abstinence. Eclectic approaches may spend only a small portion of time on those changes. The small time spent focused on those changes may not be sufficient to facilitate change, and it may give the abuser the message that those changes are relatively unimportant.

CONCLUSIONS AND FUTURE DIRECTIONS

There is no one treatment for cocaine abuse that has proven more effective than any other. The treatment of cocaine addiction is complex, and it must address a variety of problems. Like any good treatment plan, cocaine treatment strategies need to assess the psychobiological, social, and pharmacological aspects of the patient's drug abuse, and it is important to match the best treatment regimen to the needs of the patient. Programs that provide several treatment options may prove the most effective.

Evaluating programs for cocaine addiction has proven difficult. There are a number of limitations inherent in many cocaine addiction studies that prevent researchers from drawing strong conclusions from the work; these limitations have included self-selection of treatment, the lack of urinalysis data, insufficient follow-up time, a lack of independent evaluation, and the unreliable information provided by the addicts themselves.

Research continues on specific issues that may influence treatment outcome. These issues include (1) the use of other drugs including Alcohol, (2) the presence of other psychiatric problems, and (3) the severity and duration of the abuse. In general, researchers believe that recovery from cocaine addiction will be difficult unless the individual has something to lose and unless the individual believes that he or she has the power to change and make positive choices.

(See also: Adjunctive Drug Taking ; Causes of Substance Abuse ; Disease Concept of Alcoholism and Drug Abuse ; Treatment Types )

BIBLIOGRAPHY

Anker, A. L., & Crowley, T. J. (1982). Use of contingency contracts in specialty clinics for cocaine abuse. In L. S. Harris (Ed.), Problems of drug dependence 1981. NIDA Research Monograph no. 41. Washington, D.C.: U.S. Government Printing Office.

Budney, A. J., Higgins, S. T., Bickel, W.K., &Kent. L. (1993). Relationship between intravenous use and achieving initial cocaine abstinence. Drug and Alcohol Dependence, 32, 133-142.

Carroll, K. M. (1993). Psychotherapy and pharmacotherapy for ambulatory cocaine abusers. Paper presented at the NIDA Technical Review Meeting on Outcomes for Treatment of Cocaine Dependence, September, Bethesda, MD.

Carroll, K. M., et al. (1987). Psychotherapy for cocaine abusers. In D. Allen (Ed.), The cocaine crisis. (pp. 75-105). New York: Plenum.

Carroll, K. M., Rounsaville, B. J., & Gawin, F.H. (1991). A comparative trial of psychotherapies for ambulatory cocaine abusers: Relapse prevention and interpersonal psychotherapy. American Journal of Drug and Alcohol Abuse, 17, 229-247.

Childress, A. R., et al. (1993). Cue reactivity and cue reactivity interventions in drug dependence treatment. In L. S. Onken, J. D. Blaine, & J. J. Boren (Eds.), Behavioral treatments for drug abuse and dependence. NIDA Research Monograph no. 137. Washington DC: U.S. Government Printing Office.

Crits-Christoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L. S., Muenz, L. R., Thase, M. E., Weiss, R. D., Gastfriend, D. R., Woody, G. E., Barber, J. P., Butler, S. F., Daley, D., Sal-loum, I., Bishop, S., Najavits, L. M., Lis, J., Mercer, D., Griffin, M. L., Moras, K., &Beck, A. T. (1999). Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry, 56 (6), 493-502.

Foote, J., DeLuca, A., Magura, S., Warner, A., Grand, A., Rosenblum, A., & Stahl, S. (1999). A group motivational treatment for chemical dependency. Journal of Substance Abuse Treatment, 17 (3), 181-192.

Higgins, S.T.&Budney, A. J. (1993). Treatment of cocaine dependence through the principles of behavior analysis and behavior pharmacology. In L. S. Onken, J. D. Blaine, & J. J. Boren (Eds.), Behavioral treatments for drug abuse and dependence. NIDA Research Monograph no. 137. Washington DC: U.S. Government Printing Office.

Higgins, S. T., et al. (1991). A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry, 148 1218-1224.

Higgins, S. T., et al. (1993). Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, 150, 763-769.

Kang, S.-Y., et al. (1991). Outcomes for cocaine abusers after once-a-week psychosocial therapy. American Journal of Psychiatry, 148, 630-635.

Klerman, G. L., et al. (1984). The theory and practice of interpersonal psychotherapy for depression. New York: Basic Books.

Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: Maintenance strategies in the treatment of addictive disorders. New York: Guilford Press.

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Rounsaville, B. J., Gawin, F., & Kleber, H. (1985). Intrapersonal psychotherapy adapted for ambulatory cocaine abusers. American Journal of Drug and Alcohol Dependence, 11, 171-191.

Simpson, D. D., Joe, G. W., Fletcher, B. W., Hubbard, R. L., & Anglin, M. D. (1999, June). A national evaluation of treatment outcomes for cocaine dependence. Archives of General Psychiatry, 56 (6), 507.

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Stephen T. Higgins

Revised by Patricia Ohlenroth

Cocaine, Pharmacotherapy

The pharmacological treatment of Cocaine abuse is defined as the use of medication to facilitate initial abstinence from cocaine abuse and to reduce subsequent relapse. The initiation of abstinence from cocaine abuse involves reduction in the withdrawal symptoms associated with cessation of cocaine. This Withdrawal syndrome resembles depression but includes a great deal of anxiety and craving for cocaine. Craving for cocaine often persists for several weeks after abstinence has been attained, and places or things associated with cocaine use in the past, called cues, can continue to stimulate cocaine craving for many months. Because of this persistence of what is known as conditioned craving, relapse to cocaine abuse can occur after the patient has become abstinent. Preventing relapse is an important function of medication treatment.

An objective of the use of medications in cocaine dependence is to reverse changes that are caused in the brain after chronic cocaine use. These brain changes, called neuroadaptation, have been demonstrated in animal models of cocaine dependence. Chemical analyses of animal brains exposed to cocaine chronically show abnormalities in the Neurotransmitter receptors on brain cells. The brain cell receptors that are affected by cocaine include Dopamine receptors and Serotonin receptors (Harvard Mental Health Letter, December 1999). Neurotransmitters such as dopamine and serotonin may be involved in the conditioned craving that creates the risk of relapse. Researchers are also looking for hereditary factors that may determine individual differences in susceptibility, which may lie in genes that control the manufacture of neurotransmitter receptors (Harvard Mental Health Letter, December 1999).

Direct and indirect evidence that there are changes in brain receptors can be found in human studies. Prolactin is a hormone that is controlled by the neurotransmitters dopamine and serotonin. In some heavy cocaine abusers, prolactin levels are abnormally high after abuse has stopped and remain elevated for a month or more. This evidence suggests that both dopamine and serotonin brain systems are perturbed by cocaine and that the abnormality persists for some time. Other evidence of persistent abnormalities in the dopamine systems comes from brain imaging studies directly examining dopamine receptors. Positron-emission tomography (PET) studies have shown a marked reduction in dopamine receptors on brain cells that are ordinarily very rich in such receptors. This abnormally low amount of dopamine receptors persists for at least two weeks after a patient stops using cocaine. That several medications may reverse these neurochemical receptor changes has been an important rationale for their use.

In addition to direct biological indicators of neuroadaptation, neuropsychological tests have documented sustained deficits in thinking, concentration, and learning among chronic cocaine abusers. These deficits may persist for weeks after cocaine use has stopped. Researchers believe that some neuropsychological deficits may be related to reduced blood flow to the brain in abusers. One PET study showed reduced cerebral blood flow in patients that had been given cocaine (American Journal of Drug and Alcohol Abuse, May 1999).

The biological abnormalities in the brains of abusers clinically may be manifest by a characteristic withdrawal syndrome. The very early phases of this syndrome, commonly called the "crash," may involve serious psychiatric complications, such as paranoia with agitation and depression with suicide. These complications require medications for symptomatic management, including Antipsychotic agents, such as chlorpromazine and haloperidol, or large dosages of Benzodiazepines to calm highly agitated patients. Many patients self-medicate these crashes using such sedating substances as benzodiazepines or alcohol. Because this crash phase is usually relatively brief, rarely lasting more than several days, there is generally no role for sustained medication. The more important role for medications occurs during the later phase of withdrawal from cocaine, which may persist for several weeks. This later phase resembles a depressive syndrome, with substantial anxiety and craving to use cocaine. The neurobiological changes noted in both human and animal studies after chronic cocaine use correspond in time to the occurrence of this syndrome. This temporal correspondence has provided a further rationale for the use of Antidepressant medications in the treatment of cocaine dependence and withdrawal.

A wide range of pharmacological agents besides antidepressants have been tried as treatments for cocaine abuse and addiction. In general, agents include drugs that affect the production, release, re-absorption, and breakdown of dopamine, serotonin, and other neurotransmitters (Harvard Mental Health Letter, December 1999). Researchers are also evaluating medications that work as a vaccine to prevent the effects of cocaine (Vaccine Weekly, May 4, 1998).

Combination pharmacotherapies are also being researched for cocaine-dependent individuals who abuse other substances. Multiple-drug abuse in cocaine abusers often involves problems with Alcohol, Opioids and/or Benzodiazepines. The medical consequences of using these drugs in various combinations are often more severe than using each drug alone, and combinations of treatment options may be needed for many of these drugs. Specific treatments may include pharmacotherapies targeted toward cocaine as well as other drugs of abuse, such as Naltrexone for opioid abuse and Disulfiram for alcohol abuse. Opioid-derived medications have also been explored. The use of opioid-derived medications to treat cocaine dependence has an ironic twist, because Sigmund Freud had suggested that cocaine might be an appropriate treatment for morphine (an opioid) addiction. Clearly substituting one drug of abuse for another drug of abuse is a risky treatment approach, but new ideas are emerging on the use of opioids with lower abuse potential than morphine, such as Buprenorphine for patients dependent on both opioids and cocaine.

Evaluation of medications in controlled studies using double blinding and random assignment is very important, because a substantial placebo response may occur in cocaine abusers when they enter treatment, even if they are given a simple sugar pill. In double-blind, placebo-controlled studies, neither the patient nor the physician knows whether the patient is receiving active medication or placebo. Controlled studies provide the clearest indication of an efficacious medication when it is found to be significantly better than a placebo given to similar patients in a randomized and blinded manner. Randomization simply means that patients who are potential subjects for a study are randomly assigned to get either the active medication or the placebo. Choices about who will get active medication and who will get the placebo are made by chance alone and not decided by the physician based on drug-abuse severity or any other criteria. In uncontrolled tests, patients are given the medication and their response is compared with their behavior before starting treatment.

ANTIDEPRESSANTS

In controlled studies, several antidepressants have been found superior to placebo. One such antidepressant was desipramine. Desipramine was felt to promote cocaine abstinence by reducing craving. In one study of the efficacy of desipramine, cocaine use declined several weeks before cocaine craving was reduced. This delay suggested that desipramine reduced the recurrence of craving after cocaine abstinence had been attained, and thus its anticraving action might be more important for the prevention of relapse than for the initiation of abstinence. One pilot study suggested that another another antidepressant, venlafaxine, may be an effective treatment for patients with a dual diagnosis of depression and cocaine dependence (American Journal of Drug and Alcohol Abuse, February 2000).

DOPAMINERGIC AGENTS

In theory, dopaminergic agents may be useful in ameliorating early withdrawal symptoms after cocaine binges, because these agents appear to have their onset of action within a day of starting. These agents include Amantadine, bromocriptine, and Methylphenidate. Bromocriptine has been studied by several groups of investigators and has shown efficacy for some and not for others. Several trials have examined amantadine at 200 and 300 milligrams (mg) daily and found that it reduces craving and use for several days to a month. Methylphenidate was shown effective in reducing cocaine cravings in cocaine users with attention-deficit/hyperactivity disorder (ADHD). One theory for addiction among ADHD cocaine abusers is that they are medicating themselves. Methylphenidate acts on receptors like cocaine, but it acts much more slowly (Harvard Mental Health Letter, December 1999). Side effects have limited the utility of several other dopaminergic agents.

MISCELLANEOUS AGENTS

A number of other agents have been utilized to treat different aspects of cocaine abuse and dependence. Several authors report a decrease in euphoria and/or paranoia with such neuroleptics (Antipsychotic medications) as flupenthixol. Neuroleptics are said to reduce the activity of dopamine (Harvard Mental Health Letter, December 1999). Flupenthixol may be particularly useful as a treatment for cocaine abusers with schizophrenia (American Journal of Drug and Alcohol Abuse, August 1998).

Studies have begun on the development of a cocaine vaccine designed to suppress the psychoactive effect of the drug. Such a vaccine works by producing antibodies that bind to cocaine in the bloodstream and prevent it from traveling to the central nervous system, thus neutralizing the effect of the drug. Studies have found that it was possible to override the effects of the vaccine with massive amounts of cocaine, but researchers believe that such consumption would be unlikely with addicts actively working to overcome addiction. Researchers have viewed the vaccine as a complementary therapy to behavioral therapy.

MULTIPLE-DRUG USE

According to the National Institute on Drug Abuse, most cocaine-dependent people abuse other substances. More than half are alcohol dependent. Opioid and sedative dependency has also been widespread over the years. The reasons for cocaine abuse by heroin addicts are to "improve" the euphoria from heroin. These findings suggest that control of heroin abuse in many patients may directly reduce cocaine abuse, and the reduction in cocaine abuse reported by several surveys of methadone-maintenance programs support this assertion.

Combination pharmacotherapies of cocaine anticraving agents with methadone or naltrexone for heroin addiction and with disulfiram or naltrexone for alcoholism have been tried with some success. While buprenorphine, a mixed opiate agonist-antagonist, and methadone have been effective in reducing opiate use, further studies are required to substantiate efficacy in reducing cocaine use in opiate addicts. However, one small study showed that buprenorphine in combination with desipramine or amantadine facilitated some cocaine abstinence. Buprenorphine and disulfiram was also found more effective than buprenorphine alone in treating heroin addicts with a cocaine habit (Alcoholism and Drug Abuse Weekly, June 19, 2000). Disulfiram is used in the treatment of alcohol addiction, and taking it before using cocaine may block the pleasurable effects of cocaine and invoke such negative effects as anxiety and paranoia, effects that may help discourage cocaine use (Alcoholism and Drug Abuse Weekly, June 19, 2000). The antidepressant desipramine also shows some promise in promoting opioid and cocaine abstinence in opioid-maintained patients (Oliveto et al., September 1999).

An important clinical need with patients dependent on opiates, alcohol, or sedatives in addition to cocaine is for detoxification. While cocaine withdrawal is not associated with major medical complications, withdrawal from these other drugs can be medically significant and often needs specific pharmacological interventions.

(See also: Causes of Substance Abuse ; Drug Metabolism ; Research, Animal Model )

BIBLIOGRAPHY

Gawin, F. H., et al. (1989). Desipramine facilitation of initial cocaine abstinence. Archives of General Psychiatry, 46, 117-121.

Jaffe, J. H. (1985). Drug addiction and drug abuse. In A. G. Gilman et al. (Eds.), Goodman and Gilman's the pharmacological basis of therapeutics, 7th ed. New York: Macmillan.

Kosten, T. R. (1989). Pharmacotherapeutic interventions for cocaine abuse: Matching patients to treatment. Journal of Nervous and Mental Disease, 177 (7), 379-389.

Kosten, T. R., & Kleber, H.D. (Eds.). (1992) Clinician's guide to cocaine addiction. New York: Guilford Press.

Levi, F. R., Evans, S. M., Mc Dowell, D. M., & Kleber, H. D. Methylphenidate reduces drug cravings in cocaine users with ADHD. (1999, January). The Brown University Digest of Addiction Theory and Application, 18.

Levin, F. R., Evans, S. M., Coomaraswammy, S., Collins, E. D., Regent, N., &Kleber, H. D. (1998, August). Flupenthixol treatment for cocaine abusers with schizophrenia: a pilot study. American Journal of Drug and Alcohol Abuse, 24.

Lowinson, J. H., Ruiz, P., & Millman, R.B. (Eds.). (1992). Substance abuse: A comprehensive textbook. Baltimore: Williams & Wilkins.

Miller, N.S. (Ed.). (1991). Comprehensive handbook of drug and alcohol addiction. New York: Marcel Dekker.

National Institute on Drug Abuse. A community reinforcement approach: Treating cocaine addiction. Therapy Manuals for Drug Addiction.

Oliveto, A. H., Feingold, A., Schottenfeld, R., Jatlow, J., & Kosten, T. Desipramine in opioid-dependent cocaine abusers maintained on buprenorphine vs methadone. (1999, September). Archives of General Psychiatry, 56.

Smelson, D. A., Roy, A., Santana, S., & Engelhart, C. (1999, June). Neuropsychological Deficits in Withdrawn Cocaine-Dependent Males. American Journal of Drug and Alcohol Abuse, 25.

Weddington, W. W., et al. (1991). Comparison of amantadine and desipramine combined with psychotherapy for treatment of cocaine dependence. American Journal of Drug and Alcohol Abuse, 17, 137-152.

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Thomas R. Kosten

Revised by Patricia Ohlenroth

Drug Abuse: 2000 and Beyond

Drug addiction is a medical and public health problem that affects everyone, either directly or indirectly. A recent study estimated that drug abuse and addiction cost the United States more than $110 billion per year. If one adds the cost of nicotine to this figure, the number dramatically soars. Improved prevention and treatment are the best ways to reduce that cost. Fortunately, advances in science have revolutionized our fundamental understanding of the nature of drug abuse and addiction, and what to do about it.

Extensive data show that addiction is eminently treatable if the treatment is well delivered and tailored to the needs of a particular patient. There is an array of both behavioral and pharmacological treatments that can effectively reduce drug use, help manage drug cravings and prevent relapses, and restore people as productive members of society.

Three decades of scientific research and clinical practice have yielded a variety of effective approaches to drug addiction treatment. Extensive data document that drug addiction treatment is as effective as treatments for most other similarly chronic medical conditions. In spite of scientific evidence that establishes the effectiveness of drug abuse treatment, many people believe that treatment is generally ineffective. In part, this is because of unrealistic expectations. Many people equate addiction with simply using drugs, and they therefore expect that addiction should be cured quickly and permanently, and view treatment is a failure if it is not. In reality, because addiction is a chronic disease, the ultimate goal of long-term abstinence often requires sustained and repeated treatment episodes.

Drug-abuse treatment programs using medications and/or behavioral techniques can and do work. The most successful treatment programs are a complex mix of medical, psychosocial and rehabilitation services that attempt to deal with the unique needs of each individual. However, effectiveness of treatment can differ because of complex variables such as the type (s) of drug (s) to which a person is addicted, the dysfunctional lifestyles of many addicts, and time and treatment resources available to addicts and treatment personnel. Many Americans affected by drug addiction have been restored to healthy and productive lifestyles through appropriate treatment.

NEW AND IMPROVED TREATMENTS

The National Institute on Drug Abuse (NIDA) has already made considerable progress in developing a variety of effective behavioral and pharmacological addiction treatments and making them widely available to the public. For example, NIDA has taken the lead in developing readily available nicotine addiction therapies. They have also brought to the world the most effective medications to date for heroin addiction, including methadone and LAAM (levo-alpha-acetylmethadol), and have standardized behavioral interventions that have been effective in treating both adults and adolescents.

NIDA supports research to develop additional new and improved pharmacological and behavioral treatments. To this end, NIDA sponsors both a medications development program and a behavioral therapies development program. NIDA's medications development program brings the critical mass of knowledge of medicinal chemistry, molecular biology, brain function, and behavior to bear on the urgent public health problem of drug addiction to provide new medications as an effective adjunct to conventional treatment by helping to stabilize addict and allow them to succeed in their overall treatment program. Specifically, new medications are being researched to:

block the effects of abused drugs;
reduce the craving for abused drugs;
moderate or eliminate withdrawal symptoms;
block or reverse the toxic effects of abused drugs;
or prevent relapse in persons who have been detoxified from drugs of abuse.

Because behavioral interventions are the most common, and sometimes the only, treatments administered to individuals with drug addiction, NIDA also has a robust behavioral therapies development program to complement its medications portfolio. Researchers are working to develop new behavioral treatments for drug abuse and addiction and enhance the efficacy of existing ones. Psychotherapies, behavior therapies, cognitive therapies, family therapies, and counseling strategies are among the approaches currently being studied under this program. Once these treatments are proven to be safe and effective in small trials, they will be tested in larger and more diverse populations through NIDA's new National Drug Abuse Treatment Clinical Trials Network. This network will enable the rapid, concurrent testing of a wide range of promising science-based medications and behavioral therapies across a spectrum of real-life patient populations, treatment settings, and community environments.

CONCLUSION

Addiction is a treatable disease. However, there is no "one size fits all" treatment program. Treatment is typically delivered in outpatient, inpatient, and residential settings, all of which have been shown to be effective in reducing drug use and are appropriate for a specific type of patient. Drug addiction treatment can include behavioral therapy (such as counseling, cognitive therapy, or psychotherapy), medications, or a combination of both. Behavioral therapies, such as cognitive behavioral coping skills treatment, offer addicts ways for coping with their drug cravings, teach them to avoid drugs and relapse, and help them deal with relapse if it occurs. The best programs provide a combination of therapies and other services, such as referral to other medical, psychological, and social services, to meet the needs of the individual patient.

Alan I. Leshner

Heroin, Behavioral Approaches

Psychological treatments are an important component of comprehensive drug-abuse treatment. Medications such as Methadone can be used to address physical dependence and other biological aspects of addiction, but Heroin abuse is also a disorder involving maladaptive learned behavior that must be stopped and replaced by healthier behaviors. Psychological therapies help drug abusers to understand their feelings and behaviors and to make changes in their lives that will lead to ending drug use and maintaining abstinence. Drug abusers also may have psychiatric problems, such as Depression and Anxiety, and they may have problems interacting with other people or dealing with anger and frustration. These problems can also be addressed by psychological therapies. In addition, heroin abuse is a chronic relapsing disorder (i.e., many people who try to stop end up returning to drug use). Relapse to drug use following treatment is commonly attributed to environmental (e.g., associating with drug-using friends), psychological (e.g., feeling depressed or angry), and/or behavioral (e.g., having poor social skills) factors that are typically the focus of psychological interventions.

A variety of psychological treatments, often in combination with pharmacological approaches, have demonstrated effectiveness in the treatment of heroin abuse. The purpose of this article is to survey the most prominent psychological interventions currently used in the treatment of heroin abusers. Following a brief discussion of the development of heroin abuse, we describe the factors that lead people to seek treatment, the range of problems that may be characteristic of heroin abusers, and the psychological treatmentsincluding Therapeutic communities, motivational incentive therapies, counseling, psychodynamic and cognitive-behavioral psychotherapies, family therapy, and Self-Help approaches. The chapter concludes with a discussion of the effectiveness of these interventions.

DEVELOPMENT OF HEROIN ABUSE

Initial heroin use is motivated by curiosity and the desire to use it without becoming addicted. Heroin is injected into a vein (although it is sometimes inhaled), and the user experiences an immediate rush, characterized by feelings of relaxation and well-being. As use escalates, withdrawal symptoms (e.g., cramps, irritability) may appear as the drug is eliminated from the body. At this point, individuals may start using the drug both for its positive effects and for alleviating uncomfortable withdrawal symptoms. Drug use may also be motivated by an attempt to cope with feelings of Stress, hopelessness, or depression. Whatever the causes of initial use, the frequent and repeated acquisition of heroin soon becomes a priority; some addicted individuals may resort to illegal activity (e.g., stealing; prostitution) to buy illicit drugs. In addition heroin abusers are often concurrently addicted to Alcohol and/or other drugs, including Cocaine and Benzodiazepines (e.g., Valium, Zanax) that they may have started taking before or after they began using heroin. It is in the context of this addictive lifestyle that heroin abusers come to the attention of treatment providers. Heroin abusers are usually ambivalent about seeking treatment; they like taking drugs and have difficulty seeing any reason to stop. They are most likely to begin treatment following a crisis of some sorta legal, physical, family, financial, or job-related problem caused by their drug use. They are typically referred to specific treatment sites by friends, family, or the legal system, which may mandate treatment as a part of probationary sentences. The cost, location, and availability of treatment slots are all factors that affect selection of treatment setting.

TREATMENT SETTINGS

Treatment for heroin dependence is offered in publicly funded clinics that accept patients with limited resources, including those who receive public assistance. It is also treated in private programs that take patients with higher incomes and/or medical insurance. Treatment for heroin abuse is often defined by the setting in which it is delivered, not by the actual content of treatment, which may or may not differ across treatment settings. For example, outpatient and inpatient clinics may offer remarkably similar services for drug abusers. One exception is the Therapeutic Community, where the treatment philosophy and approach are uniquely associated with long-term recuperation in a residential setting. Treatments are also labeled with regard to the relative role of psychological versus pharmacological interventions used. With Methadone Maintenance, for example, counseling and psychotherapy are viewed as secondary, although complementary, to the daily oral administration of methadonea drug that replaces heroin within the dependence mode. At the opposite end of the spectrum are residential therapeutic communities and Twelve-Step self-help programs, in which the entire intervention consists of social and behavioral modeling, with no use of medications. Drug-abuse treatment may also be distinguished by whether it is offered in a hospital versus a community clinic outpatient setting. Outpatient clinics usually emphasize psychological techniques, by providing counseling and psychotherapy services. Hospital chemical dependency units usually offer medical detoxification that involves prescribed medications along with some combination of psychological approaches. These detoxification services are important for helping hero independent people make the transition to a drug-free state. However, it is also important that they continue in treatment at the same or another state program after the detoxification has been completed. Those who follow this recommendation are more likely to remain abstinent and to continue working on the lifestyle changes needed for long-term successful outcomes. In this chapter, we will describe the content of psychological interventions for heroin abuse independent of the settings in which they are typically administered.

ASSESSMENT

By the time drug abusers seek treatment, they often have a number of problems that need to be solved, only the first of which is stopping drug use. Within any treatment setting, comprehensive assessment is essential to focus treatment on the areas where change is needed. It is first important to understand the types and amounts of drugs that are typically taken in order to assess the severity of the drug-abuse problem. Drug-use information is assessed through the patient's self-report and urinalysis testing. Urinalysis testing provides objective information about whether the individual has or has not used drugs recently and can also be used to verify the truthfulness of self-reports. An understanding of psychological and environmental factors that precede and follow drug use (e.g., when, where, and why drugs are taken; where and how the drugs are acquired), known as a functional analysis, is also necessary for the development of strategies to initiate abstinence and prevent relapse. Evaluation of psychiatric disorders is essential for determining appropriate treatment intervention. Depression and Antisocial Personality, for example, are quite common among heroin abusers (Brooner et al., 1997). Some problems, however, such as depression, may go away when drug use stops. Finally, social functioning, employment history, and illegal activity all have implications for psychological interventions and treatment prognosis and need to be thoroughly assessed. Indeed, being employed and having good social support (e.g., from a spouse who does not abuse drugs) are excellent predictors of treatment success if they are already present, and areas that need attention in treatment if they are not. The Addiction Severity Index (ASI; McLellan et al., 1992), a structured interview that assesses drug use, physical and emotional health, employment, social support, and legal status, is often used by clinicians and researchers to evaluate the broad range of factors that are related to drug abuse and may improve with treatment.

PSYCHOLOGICAL AND BEHAVIORAL TREATMENTS OF HEROIN ABUSE

This section will survey common psychological and behavioral approaches to the treatment of heroin abuse. Although each differs in regard to its philosophy and goals, all share an interest in eliminating the drug use of the heroin abuser and the substitution of healthier behaviors.

Therapeutic Communities.

Therapeutic communities (TCs) are long-term (6-24 month) residential programs developed specifically for helping drug abusers change their values and behaviors in order to sustain a drug-free lifestyle. The assumption behind these communities is that drug abusers, who have typically been involved in a special illicit sub-culture for most of their lives, need to learn how non-drug-abusing individuals function in society. The goal is to rehabilitate the drug abuser into a person who can conform to society's values and goals, assume social and job responsibilities, and make contributions to the community. During treatment, the drug abuser lives in a special residential community with other drug abusers and with therapists who may be ex-addicts in recovery. A behavioral shaping/incentive system is set up so that desirable behaviors are rewarded through community privileges and increased responsibilities. In addition, patients learn through observing peers and staff, who serve as role models for appropriate behavior, sometimes called "right living."

Patients progress through three stages. In the first stage, orientation (0-2 months), the patient assimilates within the therapeutic community by attending seminars concerning the philosophy and rules of the program. The second stage is called primary treatment (2-12 months) and characterized by increasing work responsibilities and group leadership roles. This stage includes three phases. In the first phase (2-4 months), patients conform to the TC policies by following the rules, engaging in low-level work assignments, and attending group meetings. By the second phase (4-8 months), patients work at more responsible jobs, actively participate in group meetings, and begin to assume the responsibility of a role-model for other patients. In the third phase (8-12 months), patients engage in top-level jobs (e.g., coordinating services in the program), colead support and treatment groups, and become social leaders in the community. The final stage, reentry (12-24 months), focuses on preparing the patient to separate from the TC and rejoin the outside community. It is expected that after leaving patients will establish their own households and obtain regular employment or continue their education. In summary, TCs attempt to rehabilitate the drug abuser by instilling a whole new set of attitudes and behaviors that conform to those expected by a non-drug-abusing society. Treatment programs modeled after therapeutic communities are becoming increasingly popular for implementation in prison systems. Typically, prisoners with a drug-abuse history are invited to join the program 6-12 months prior to their scheduled release date. In most successful programs, involvement with residential treatment continues after release from prison, a time when prisoners most need help with reentering the community and establishing a drug-free lifestyle.

Drug-Abuse Counseling.

This intervention approach is practiced in methadone maintenance programs, where patients are required to see a counselor throughout the course of treatmentand may also be provided in outpatient community-clinic programs. Counselors are usually professionals with a college degree in counseling, although ex-addicts who have personal experience with recovery from drug abuse may also provide counseling. Counselors have several roles. First, they monitor treatment compliance (that the patient is attending regularly and providing urine specimens for drug testing as requested), confront any violations of program rules, and enforce penalties and privileges. Second, based on problems and deficits identified during the assessment phase, counselors formulate a treatment plan that specifies goals for the patient. For example, a treatment plan may contain recommendations to abstain from drug use, obtain employment, and participate in self-help groups. Counselors work with their patients using several strategies to implement such a treatment plan. Goal setting helps patients learn to set reasonable goals that will lead to a responsible drug-free life (e.g., finding a job, starting a bank account, obtaining a driver's license) and to outline specific steps required to attain chosen goals. In problem-solving training, counselors and patients work together to address both immediate and longstanding problems in the patient's life. The primary goal is for patients to learn the strategies for solving everyday problems and for making decisions. Recreational planning may be used to encourage patients to engage in new social and recreational activities that might substitute for their typical lifestyle of searching for drugs or hanging out with drug-using friends. Finally, counselors are expected to refer patients to other community-helping agencies for services that they cannot provide themselves. For example, patients who are unemployed may be referred to an employment-counseling service. In summary, counseling attempts to comprehensively address the problems of drug abusers using practical, goal setting, and problem-solving techniques.

Motivational Incentive Therapy.

The goal of motivational incentive therapy is to offer a therapy that can more effectively compete with the powerful enticement of drugs and make abstinence a more attractive option. It does this by offering immediate and tangible benefits to the addict for remaining abstinent. In a motivational incentive program, drug abusers in treatment can earn points that are worth money each time they submit a urine sample that tests negative for specified drugs (e.g., heroin and cocaine). The incentive program is designed to promote sustained abstinence. To do this, the number of points earned for each consecutive drug-free sample increases over time and "resets" to the original lower number if the patient relapses to use and submits a drug-positive sample. In general, the more money that is offered, the more successful the incentive program. For example, in some of the most successful research programs, patients have been able to earn up to $1000 if they remained continuously abstinent for 3 months. Although this amount may seem high, it is reasonable compared to the costs of continuing drug abuse to society. Patients like the incentive program because they can use the money earned to improve their life. For example, they can pay bills or exchange gift certificates for groceries and other retail items. The incentive program is not intended to last indefinitely; 3 to 6 months is typical. However, the program helps keep patients in treatment and promotes abstinence. During periods of sustained abstinence engendered by an incentive program, counselors and clients can work on making the lifestyle changes that will promote more enduring abstinence after the incentive program ends.

Psychotherapy.

This type of psychological treatment, usually practiced by trained clinical psychologists, psychiatrists, or psychiatric social workers during a one-on-one interaction with the patient, uses interpersonal skills to promote insight and behavior change. Psychotherapy was developed for use with neurotic and emotional disorders, but has been adapted for use with drug abusers. Several specific types of psychotherapy are practiced by various therapists, depending on their training, with psychodynamic and cognitive-behavioral being two prominent types. In each of these therapies, comprehensive assessment, empathic listening, nonjudgmental understanding, and patience are necessary tools to help the patient become involved in a therapeutic relationship and provide a context for behavior change.

Psychotherapy can also be practiced in groups, and group treatment is frequently defined as a separate type of treatment. Groups are a popular way to conduct treatment and may be found in virtually any treatment setting, including hospital and outpatient chemical dependency programs, methadone programs, and therapeutic communities. The content of therapy, however, can vary widely from one group to another in the same way that differing approaches are used for individual psychotherapy. Regardless of therapeutic approach, group therapies do differ from individual therapies in some specific ways. Groups provide a context for mutual empathy, encouragement, and support among people who share similar problems. Patients in groups may benefit from the experience of others in solving these problems and by entering reciprocal helping relationships. The interactions among group members also provide a context in which the therapist can facilitate improved social skills for those who may need them.

Psychodynamic Therapy.

Psychodynamic therapy with heroin abusers employs supportive, analytical techniques to explore heroin use and the addictive experience from the patient's point of view. Drug use is viewed as a symptom of underlying emotional problems and/or relationship difficulties. Thus, psychodynamic therapy rarely confronts or attempts to modify drug use directly, and for this reason, it is usually implemented after stable abstinence from drugs has been achieved. Therapy focuses instead on the patient's thoughts, feelings and relationships (past and present) with parents, spouse, friends, and other significant individualsfrom which the therapist tries to identify common patterns or themes. As therapy progresses, the therapist-patient relationship becomes the focal point, as this relationship often replicates themes from interactions with others, which the therapist points out. The primary means of behavior change results from the patient recognizing these common, often maladaptive, interaction themes and determining to change them. Thus, the goal of treatment is for the patient to understand the origin and function of their feelings and behavioral patterns, and to use this awareness to change the manner in which they cognitively interpret, emotionally respond, and behaviorally interact with individuals in their environments. For example, a psychodynamic therapist might observe that anger is a continuing theme in a patient's life and be sensitive to situations when the patient shows anger toward the therapist. When this happens, the therapist will help the patient understand the circumstances leading to the anger and relate these circumstances to other situations when the patient had been angry. Eventually, the patient and therapist might explore the origins of the patient's anger (perhaps toward his or her parents) and the relationship between the patient's anger and engaging in self-destructive behavior (e.g., drug use). As the patient develops more adaptive ways of coping with thoughts, emotions, and relations to others, heroin and other substance use becomes less necessary and desirable. In summary, psychodynamic therapy views long-term abstinence from drug use as an indirect result of resolving the causes of drug use. In this way, it is believed that a more permanent cure will result.

Cognitive-Behavioral Therapy: Relapse Prevention.

Cognitive-behavioral therapists are concerned with direct interventions that will change behavior and thinking without necessarily requiring or expecting insights into the causes of behavior. Recognizing that relapse is a serious problem in drug abuse, these therapy approaches have been specifically adapted for use with heroin and other drug abusers in a therapy called Relapse Prevention, to teach them the skills necessary to initiate and sustain abstinence (Marlatt & Gordon, 1985). A functional analysis derived in the assessment phase allows the therapist to understand the thoughts, behaviors, and environmental conditions that precede and follow heroin and other drug use and to help the patient recognize the environmental (e.g., drug-using friends), cognitive (e.g., irrational thinking), emotional (e.g., anger), and behavioral (e.g., starting arguments) factors that may either reduce the likelihood of stopping or increase the likelihood of returning to drug use. Based on this functional analysis, the cognitive-behavioral therapist and the patient decide which factors (e.g., thoughts, places, people) are most likely to sustain ongoing drug use or act as triggers for relapse during abstinence; then specific treatments are based on this analysis (Carroll et al., 1994).

Patients and therapists may work together to devise strategies for avoiding drug-using friends and staying away from places in which the patient has bought and used drugs in the past. In some cases, patients may even want to change their phone numbers or move to new locations. In addition to environmental changes, heroin abusers may be taught new skills designed to help them cope with high-risk situations that could trigger relapse. For example, patients who use drugs when they feel stressed may be taught specific relaxation techniques that can counteract stressful feelings. Patients may also learn drug-refusal skills to handle situations where they actually encounter drugs (although it is better to avoid such situations altogether) and to use specific strategies for coping with situations in which the return to drug use is likely (e.g., calling a nonusing friend; leaving the situation; making an appointment with their therapist). In addition, cognitive-behavioral therapists may address the patient's thought patterns that precede heroin use and call attention to dysfunctional thinking. For example, patients may have unrealistic thoughts ("I must be loved and accepted by everybody or else I am a failure and might as well use drugs") or illogical thoughts ("I will never be able to stop using drugs because I am an addict"). The cognitive-behavioral therapist aims to change negative cognitions to adaptive, positive thinking ("I do not need everybody's approval"; "I can learn to gain control over my behavior").

Sometimes a pervasive maladaptive behavior pattern underlies drug abuse that can be addressed with a cognitive-behavioral approach. For example, with a patient who has trouble controlling anger and tends to use drugs after angry confrontations, the cognitive-behavioral therapist may place the patient on an anger-control skills-training program. The patient would be instructed to avoid situations likely to induce anger (e.g., confrontations with a supervisor) and would be taught specific strategies for dealing with potential anger-producing situations. For example, relaxation might be employed to gain control over anger. Further, the patient might be taught new self-statements to replace thoughts that have typically preceded feelings of anger (e.g., "It would be nice to get a raise, but it isn't the end of the world if I do not get it"). In summary, cognitive-behavioral therapy focuses directly on behavior change without expecting or requiring insight into the cause of the problem. To the extent that underlying emotional and interactional dysfunctions often exacerbate drug use, however, both the cognitive-behavioral and the psychodynamic therapist will end up dealing with the same issuesalbeit in slightly different ways.

Family Therapy.

Heroin abusers are often raised in dysfunctional families and may replicate the mal-adaptive behavior patterns learned from their families within their own personal and romantic relationships. In addition, the patient's heroin abuse may have had a disruptive effect on that family. These observations suggest the importance of including the family in the treatment process, and this is particularly true for adolescents who become involved with drugs while still living with their families. For older drug abusers, it is often difficult to involve the family in treatment, and family resistance/avoidance is one of the first issues that the therapist must address. Family therapy is a specialized type of psychotherapy that has its own methods, in which practitioners must be trained. Thus, it is generally conducted by a psychologist or other health professional who has been trained in one of several specific familial treatment approaches. Although there are several theoretical perspectives to family therapy (e.g., psychodynamic, cognitive-behavioral, family systems, etc.), the goals of these types of interventions are to help the family recognize maladaptive patterns of behavior, to learn better ways of solving family problems, to better understand each other's needs and concerns, and to identify and modify family interactions that may be helping to maintain drug use in the targeted family member (or members).

Self-Help Groups.

Alcoholics Anonymous (AA) was created in 1935 by recovering alcoholics so that alcoholics could help each other abstain. Narcotics Anonymous (NA) and Cocaine Anonymous (CA) were later based on the tenets of AA but geared toward drug addictions. The newest group is Methadone Anonymous (MA), which accommodates drug addicts who use methadone. The core beliefs espoused by self-help groups are commonly adopted by many treatment programs, and drug-abuse patients are often referred to self-help groups as an adjunct to other treatments. Active members of self-help groups attend frequent meetings, some as often as once per day. At these meetings, members speak to each other about their drug use and drug-related problems; they offer mutual advice and support without the help of any trained therapists.

The philosophy, treatment goals, and procedures of self-help groups are contained in a book called The 12 Steps to Recovery. This book, often referred to as "The Big Book," outlines a series of tasks designed to promote abstinence and long-term recovery among alcoholics and drug abusers. The first step in recovery is to admit that one has a problem with drugs and/or alcohol and that outside help is needed to solve the problem. The sources of help to be called upon are other group members and a higher spiritual power (e.g., God), who will supply the spiritual strength necessary to stop drug use. The twelve-step program also advocates specific practical changes in lifestyle; these revolve around regular and frequent attendance at group meetings and concentration on the goal of abstinence (e.g., remembering the motto "one day at a time"). Once stable abstinence is achieved, the drug user is encouraged to restore relationships with friends and family that have been damaged by former drug use. For some, however, the self-help community becomes the primary source of friendships and social support.

Sponsorship is another technique used to promote and sustain abstinence. Specifically, all group members are encouraged to work with a sponsor who is typically an older, long-standing, group member who models appropriate behavior, guides new members through the twelve-step process, and provides a source of support for the new member to turn to in times of crisis. Later, the new member may sponsor someone else. To the extent that self-help programs permit former drug abusers to receive support from peers, associate with new groups of non-drug-using friends, and engage in alternate recreational activities with newly developed social contacts, the goals and even processes are similar to therapy. However, these goals are accomplished through group support and modeling using a treatment plan laid out in the twelve-step code rather than through formal meetings with a professional therapist.

EFFECTIVENESS OF PSYCHOLOGICAL TREATMENTS FOR HEROIN ABUSE

An end to drug use is the primary outcome measure for evaluating the effectiveness of drug-abuse treatment. Urine testing is usually included as a routine part of any drug-abuse treatment, to provide objective information on whether the treatment is being successful at motivating the patient to stop drug use and maintain abstinence. Changes in criminal behavior, employment status, family problems, and physical and emotional health are also relevant to understanding the effectiveness of treatment. Many of these collateral difficulties improve once drug use is stopped, although more improvement would be expected in treatment programs that offer services to specifically address these collateral problems. Using this array of outcome measures, studies have been conducted to evaluate the relative efficacy of treatments for heroin abusers. These studies have typically focused on the treatment setting rather than the content of treatment that is delivered within each setting. Further, some treatment settings have received much more evaluation than others. Methadone maintenance and TCs, for example, have received lots of attention, whereas hospital chemical-dependency programs have been infrequently evaluated and self-help programs have not been evaluated at all (Gerstein & Harwood, 1990).

Large scale followup studies such as the Treatment Outcome Prospective Study (TOPS), the Drug Abuse Treatment Outcome Study (DATOS), and the Drug Abuse Reporting Program (DARP), which have surveyed outcomes from methadone, therapeutic community, and outpatient modalities, have found that drug abusers who enter treatment display less drug use and better social adjustment during and following treatment than they did prior to treatment and also have better outcomes than groups of patients who applied for treatment but never followed through (Hubbard et al., 1989: Simpson & Sells, 1990; Simpson & Curry, 1997). These studies also found that effectiveness does not seem to be related to type of treatment but rather to duration of stay in treatment. Several types of treatment can be effective, but only with those patients who remain for prolonged periods of time. Thus, methadone maintenance and therapeutic-community treatments produce similar degrees of success with those who staybut more patients tend to stay in methadone than in TC treatment. Finally, the success of drug-abuse treatment in general is better for patients who exhibit the fewest psychiatric symptoms and the greatest social stability (McLellan, 1983).

When evaluation focuses on treatment setting rather than on treatment content, it becomes difficult to determine which components of treatment are responsible for outcome results. This is especially true since treatment programs for heroin abuse are typically comprehensive and multimodal, encompassing a variety of techniques that may include psychological and behavioral interventions, medications, and self-help. The few well-executed studies that have attempted to evaluate the impact of specific psychological interventions on heroin abusers have been conducted with methadone maintenance programs. These studies have shown that methadone-maintenance treatment outcome is enhanced by a variety of psychological interventions, including counseling (McLellan et al., 1988, 1993), individual psychotherapy (Woody et al., 1983), family therapy (Stanton & Todd, 1982), cognitive-behavioral/relapse prevention aftercare (McAuliffe, 1990), and motivational incentive/contingency management therapy (Higgins, et al., 1993; Petry, 2000; Silverman et al., 1998) as evidenced by reduced drug use and crime, plus improved social and psychological functioning.

SUMMARY

Research has shown that several different types of treatment for heroin abusers can be effective. Heroin abusers who enter treatment do better than those who apply but do not follow through with treatment. Heroin abusers who remain in treatment the longest achieve better treatment outcomes than those who drop-out early. In addition, heroin abusers who exhibit the fewest psychiatric symptoms and demonstrate the most social stability appear to benefit most from treatment. Finally, specific psychological interventions have enhanced the effectiveness of methadone maintenance treatment. As previously noted, heroin abuse is a chronic, relapsing disorder: It appears that long-term treatment and perhaps repeated treatment may be necessary to eliminate drug use and to successfully address the broad range of psychosocial difficulties that usually accompany this disorder.

(See also: Addiction: Concepts and Definitions ; Causes of Substance Abuse ; Coerced Treatment for Substance Offenders ; Drug Testing and Analysis ; Opioid Dependence ; Opioid Complications and Withdrawal ; Tolerance and Physical Dependence ; Treatment, History of ; Treatment Types ; Wikler's Pharmacologic Theory of Drug Addiction )

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Maxine L. Stitzer

Michael Kidorf

Heroin, Pharmacotherapy

Heroin abuse has been a social problem for many years. Heroin was trademarked after its first synthesis and use by the Bayer pharmaceutical company in Germany in 1898. It is derived from Morphine, the natural alkaloid complex that is found in opium. Although heroin is taken into the body by a number of routes, the most common is injection. The rapid absorption of injected heroin into the bloodstream causes a large "high" and a "rush," at first (before tolerance occurs), and all the heroin is absorbed by this route.

Another method, smoking heroin, has been called "chasing the dragon," perhaps as an allusion to Chinese opium smoking; in this method, heroin is placed on a metallic foil and a match lit under it. When the heroin vaporizes, the vapor is inhaled through a straw; liquid heroin rolls around on the foilhence the chase. A third method of heroin use, which waxes and wanes in popularity as the purity of illicit street heroin changes, is insufflation (snorting). This method minimizes the risks of intravenous drug use, including blood-borne infectious diseases such as hepatitis and Hiv /Aids, but it does not produce a rush because absorption into the bloodstream is slow. Heroin can also be injected into a muscle or under the skin (known as skin popping).

At first, heroin users have few lingering effects after a dose. The drug effects wear off after about six hours. Over time, however, addicts develop tolerance to the dose and dependence on the drug. Addicts will begin using heroin because they see people (friends, family, peers, role models) using it or because they feel a need to try it. As the frequency of use increases, they begin to experience withdrawal symptoms when they are not using the drug. At this point, they are physically dependent on heroin and will require larger and larger doses of heroin to achieve the same high or any high at all. Many addicts report that tolerance develops to such an extent that they cannot use enough for a high but must continue to use it to just feel normal (i.e., not be in withdrawal). It takes several weeks for a naive user to become dependent with this type of regular use.

HISTORICAL OVERVIEW OF TREATMENTS

When heroin was first commercially marketed by the Bayer Company as a morphine-like cough suppressant, it was thought to have fewer side effects than morphine. It was also used in the "treatment" of morphine addiction since it enters the brain more rapidly than does morphine. Instead, heroin introduced a new, more potent addiction. An over-the-counter industry in the legal sale of morphine and codeine elixirs also existed until opiates were outlawed by the Harrison Narcotics act of 1914 and subsequent laws were passed during World War I (1914-1918).

Treatment of heroin abuse in the United States was initially targeted at removing the drug user from the environment of use. The federal prison in Lexington, Kentucky, became the site where incarcerated heroin addicts in federal custody were sent. Much of the current knowledge about opiate abuse was gained from the careful observations and carefully controlled studies of the researchers there. After incarceration, the addicts often returned to their towns of origin, and most of them turned back to drug abuse. The resulting clinical observation has been that imprisonment alone (with no drugs available) is an ineffective treatment of heroin abuse.

Historically, many of the medications used to treat heroin withdrawal in the general public have been largely ineffective; in some cases, the cure has been worse than the disease. Among the numerous ineffective treatments have been Thorazine, Barbiturates, and electroshock therapy. In one method, belladonna and laxatives were used, because of the incorrect supposition that narcotics needed to be "rinsed" from the bodily tissues in which they were stored. At one institution that used this treatment, six of 130 addicts died during such opiate detoxification. Commenting on these methods, two of the researchers at Lexington noted: "The knockout feature of these treatments doubtless had the effect of holding until cured many patients who would have discontinued a withdrawal treatment before being cured, and the psychological effect of doing something for patients practically all the time has a tendency, by allaying apprehension, to hold them even though what is done is harmful" (Kolb & Himmelsbach, 1938). Since the research conductetd at Lexington from the 1930s to the 1950s, which showed that opiate withdrawal was not fatal (unless complicated by other disorders or treatments), more standardized methods of detoxification have been developed.

A true advance was the development of methadone as a long-acting, orally effective opioid. Methadone was developed in Nazi Germany and was given the trade name Dolophine by the Eli Lilly company (from dolor, pain). The advantages of methadone over heroin include methadone's effectiveness when taken by month; its long action, which allows single daily doses; and its gradual onset and offset, which prevents the rapid highs and withdrawal seen with heroin. Methadone-maintenance treatment was developed in the 1960s in New York City and has become an accepted treatment for opioid dependence. With the discovery that HIV infection can be transmitted by intravenous drug users, the benefits of methadone in decreasing intravenous heroin use have become even more evident.

PHARMACOLOGICAL TREATMENT APPROACHES

The most common and first-line treatment approach is to try to get the addict to stop using heroin by detoxification. Detoxification refers to using medications to treat withdrawal symptoms. The heroin withdrawal symptoms are similar to the symptoms of a severe flu. Although these withdrawal symptoms are rarely medically dangerous for those in good health, they are extremely uncomfortable, and, in many addicts, they make the alternative, using heroin, more attractive than detoxification. Severe withdrawal is associated with signs of sympathetic nervous system arousal as well as increased pulse, blood pressure, and body temperature. Addicts experience sweating, hair standing on their arms (i.e., goosefleshhence the expression "cold turkey"), muscle twitches (from which the expression "kicking the habit" comes), diarrhea, vomiting, insomnia, runny nose, hot and cold flashes, and muscle aches. A host of psychological symptoms accompany the withdrawal distress. After addicts have been detoxified, they may be treated with medications that make it less likely they will use heroin again; these medications that prevent relapse may work by blocking heroin's effects. Medications can also be used to treat underlying psychiatric problems that contributed to the addict's use of drugs.

An alternative approach is Methadone Maintenance, which does not initially aim to stop the addict from using opioids but instead to substitute oral methadone use for heroin abuse. Methadone is a clear liquid, usually dissolved in a flavored drink, that is given once a day and is prescribed by a physician. Used as a way to treat addicts' withdrawal symptoms and drug craving, the prescription of methadone is closely controlled by state and federal regulations.

Opiate Detoxification.

The simplest approach to detoxification is to substitute a prescribed opioid for the heroin that the addict is dependent on and then gradually lower the dose of the prescribed opioid. This causes the withdrawal to be less severe, although the withdrawal symptoms may last longer. A typical procedure entails first verifying that addicts are dependent on opioids (by some combination of observed withdrawal, a withdrawal response to naloxone, or evidence of heavy opioid use). The addicts are then given an appropriate dose of methadone, which treats the withdrawal symptoms. They are monitored for oversedation due to methadone or undermedication of withdrawal symptoms. Intravenous users of street heroin admitted to the hospital usually tolerate well a starting methadone dose of 25 milligrams. The methadone dose is then gradually lowered over the next several days. It is typical to taper a starting methadone dose of 25 milligrams over a period of seven days.

Another approach avoids the difficulties of prescribing an opioid to an addict. It involves using the antihypertensive Clonidine to treat withdrawal symptoms after the addict has stopped using the opiates. Clonidine suppresses many of the physical signs of opiate withdrawal, but it is less effective against many of the more subjective complaints during withdrawal such as lethargy, restlessness, and dysphoria. Clonidine's side effects of low blood pressure, sedation, and blurry vision make it unpleasant to take and unlikely to be abused by addicts. Although clonidine has not been approved by the Food and Drug Administration for opiate detoxification, it is widely used for this purpose and has demonstrated efficacy. It is most effective when used in addicts who are not addicted to large doses of opioids.

Opiate Antagonists.

The opiate antagonist Naltrexone is used clinically to accomplish rapid detoxifications and to help detoxified addicts stay off opioids. Naltrexone binds more strongly than heroin to the specific brain receptors to which heroin binds. If, therefore, addicts who are dependent on heroin take a dose of naltrexone, the naltrexone will replace the heroin at the brain receptor and the addicts will feel as if all the heroin has been suddenly taken out of their body. The effect of this rapid reduction in effective heroin (at the receptor) is withdrawal. The withdrawal is usually more severe than that which comes from simply stopping the heroin, but it also has the effect of accomplishing a detoxification more quickly. Thus, a combination treatment of clonidine to suppress the intensity of withdrawal symptoms and naltrexone to accelerate the pace of withdrawal has been used for rapid detoxification.

Naltrexone is primarily used after detoxification to prevent addicts from returning to opioid use. Because naltrexone binds to opioid receptors more tightly than does heroin, opioid addicts on naltrexone who use heroin will find the heroin effect blocked by naltrexone. Addicts maintained on naltrexone who use heroin will only be wasting their money. One effect of naltrexone is thus to extinguish the conditioned response to heroin injection. Naltrexone is prescribed in the form of a pill that can be given as infrequently as three times a week. It has few side effects in the majority of patients who take it, and, contrary to some rumors, it does not suppress other "natural highs."

Opioid Maintenance.

Methadone is the most common opioid used for the maintenance treatment of opioid addicts. Methadone satiates the heroin user's craving for heroin in order to prevent heroin withdrawal. The more important therapeutic effect of methadone, however, is tolerance to it. Addicts maintained on a stable dose of methadone do not get high from each dose because they are tolerant to it. This tolerance extends to heroin, and methadone-maintained addicts who use heroin experience a lesser effect because of the tolerance. Tolerance accounts for the fact that methadone-maintained addicts can take methadone doses that would cause a naive (i.e., first-time) drug user to die of an overdose. Generally, methadone-maintained addicts do not appear to be either intoxicated or in withdrawal. Tolerance is admittedly incomplete, and methadone-maintained addicts have some opioid side effects that they do not become tolerant tofor example, constipation, excessive sweating, and decreased libido. There is no known medical danger associated with methadone maintenance, however.

Methadone is dispensed as part of licensed programs, usually on a daily basis. It is generally well received by addicts, and the risk of incurring withdrawal symptoms if methadone treatment is interrupted provides a strong incentive for addicts to keep appointments. The ritual of daily clinic attendance has the additional therapeutic benefit of beginning to impose structure on the chaotic lives of most opiate addicts. Methadone treatment is often augmented with medical, financial, and psychological support services to address the many needs of opioid addicts.

Despite the philosophical debates about the appropriateness of using methadone, there is a large body of evidence indicating that methadone-maintained addicts show decreases in heroin use, crimes committed, and psychological symptoms. The major drawbacks to methadone maintenance include the great difficulty of achieving detoxification from methadone, the methadone side effects, and the possibility of increased use of other illicit drugs such as cocaine.

An opiate addict initially coming in for treatment will usually be put through detoxification and possibly put on naltrexone maintenance. Addicts with intact family supports, good jobs, or strong motivation are more likely to benefit from naltrexone maintenance than those who are more impaired. Younger addicts and adolescents are urged to try nonmethadone approaches, so as to avoid developing a methadone addiction. Methadone maintenance is usually reserved for patients who have failed at previous detoxifications. An exception is made for pregnant women, in whom methadone maintenance is the treatment of choice, with detoxification of the infant from methadone accomplished after birth. Opiate detoxification is risky in pregnant women because of the adverse effects on fetal development in the first and second trimesters, and the risk of miscarriage.

Other nonmethadone medications for maintenance treatment of opioid dependence have not yet been widely used. Buprenorphine is a partial opioid agonist medication that has the advantages of being safe, even at higher doses, and being associated with less severe withdrawal symptoms than methadone after discontinuation. Another medication recently approved for treating opioid dependence is LAAM (levo-alpha-acetylmethadol). LAAM is broken down in the body to very long-acting active metabolites, and therefore it can be prescribed as infrequently as three times a week.

THE INTEGRATION OF PHARMACOLOGICAL AND PSYCHOSOCIAL TREATMENTS

No medication will prevent an addict who wants to use heroin from doing so. Naltrexone maintenance can be discontinued, and addicts who discontinue it are able within one to three days to use heroin without the naltrexone blockade. Similarly, methadone maintenance is ineffective in addicts who are unable or unwilling to meet the requirements of clinic attendance (which sometimes requires payment of fees) and staying out of prison. Addicts whose lives are in disarray require medications as part of a comprehensive treatment program that also addresses their other needs. In a street addict who chronically uses drugs, these may include needs for counseling, medical attention, vocational rehabilitation, and a host of other services. There is evidence that methadone treatment is more effective if a higher "dose" of psychosocial treatment is provided along with it.

Detoxification is a first step toward recovery because it makes the addict available to further psychosocial and medical treatments. There is evidence that mild physiological abnormalities due to withdrawal of opiates linger for as long as three months after detoxification. This "long-term abstinence syndrome" is thought to contribute to the craving for opiates that occurs after detoxification. Naltrexone maintenance is most effective in addicts who have jobs and stable social supportsfor example, in anesthesiologists who have become addicted to hospital medications. Because naltrexone itself is not reinforcing and many heroin addicts have a host of psychosocial problems, many clinics have reported that naltrexone maintenance alone was minimally effective in the treatment of long-term addicts.

SUMMARY

Opioid addiction is, in many ways, a physical problem as well as a psychological and behavioral problem. Addicts become physically addicted to opiates and, in the later stages of addiction, become preoccupied with relieving the physical symptoms of withdrawal. They become highly attuned to the bodily signals that withdrawal is coming. Heroin addicts spend most of their waking life procuring, using, and withdrawing from herointhree times a day, seven days a week, fifty-two weeks a yearfor years.

The medications used to treat opioid abuse are powerful agents that interrupt this cycle. Although medications alone rarely cure an addiction, they are critically important to breaking the cycle of preoccupation with opioid use and enabling addicts to benefit from comprehensive drug-abuse treatment.

(See also: Coerced Treatment for Substance Offenders ; Ibogaine ; Opioid Dependence ; Opioid Complications and Withdrawal ; Pregnancy and Drug Dependence ; Substance Abuse and AIDS ; Treatment Types )

BIBLIOGRAPHY

Beers, M. H., & Berkow, R. (Eds.) (1999). The Merck Manual of Diagnosis and Therapy, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories.

Brophy, J. J. (1994). Psychiatric Disorders. In L. M. Tierney et al. (Eds.), Current Medical Diagnosis & Treatment, 33rd ed. Norwalk, CT: Appleton & Lange.

Kolb, L., & Himmelsbach, C. K. (1938). Clinical studies of drug addiction. III. A critical review of the withdrawal treatments with methods of evaluating abstinence syndromes. Public Health Reports, 128 (1). Cited in H. D. Kleber (1981), Detoxification from narcotics. In J. H. Lowinson & P. Reiz (Eds.), Substance abuse: Clinical problems and perspectives. Baltimore: Williams & Wilkins.

Greenstein, R. A., Arndt, I. C., Mc Lellan, A. T., O'Brien, C. P., & Evans, B. (1984). Naltrexone: a clinical perspective. Journal of Clinical Psychiatry, 45 (9 Pt 2), 25-28.

O'Brien, C. P. (1996). Drug addiction and drug abuse. In J. G. Hardman et al. (Eds.), Goodman and Gilman's The Pharmacological Basis of Therapeutics, 9th ed. New York: Mc-Graw-Hill.

O'Brien, C. P., Childress, A. R., Mc Lellan, A. T., Ternes, J., & Ehrman, R. N. (1984). Use of naltrexone to extinguish opioid-conditioned responses. Journal of Clinical Psychiatry, 45 (9 Pt 2), 53-56.

Substance Abuse and Mental Health Services Administration (SAMHSA). (1999). 1998 National Household Survey on Drug Abuse. Washington, DC: U.S. Department of Health and Human Services.

Wilson, B. A., Shannon, M. T., & Stang, C. L. (Eds.) (1995). Nurses Drug Guide, 3rd ed. Norwalk, CT: Appleton & Lange.

Marc Rosen

Revised by Rebecca J. Frey

Marijuana, An Overview

Although marijuana is the most widely used illicit drug in the U.S., fairly little is known about how to effectively treat individuals who become dependent on this drug. Increasingly, however, the findings of controlled trials designed to evaluate the effectiveness of alternative counseling approaches are appearing in the literature. Additionally, recently acquired knowledge about the actions of a marijuana-like compound that occurs naturally in the brain will enhance our understanding of the nature of marijuana dependence and possibly set the stage for the development of pharmacological interventions.

Prevalence of Marijuana Dependence.

The most widely used illicit substance in the U.S., it is estimated that seventy-two million people have ever used the drug and eleven million are doing so currently (i.e., at least once in the past month). Nearly seven million reported using marijuana weekly or more often in 1998, and approximately two million individuals begin use of marijuana each year (SAMHSA, 1999).

Epidemiological studies conducted in the last two decades permit an estimation of the prevalence of marijuana dependence in the United States. In the 1980s, the Epidemiological Catchment Area (ECA) study involved in-person interviews with 20,000 Americans in five urban areas (Anthony & Helzer, 1991). The study's purpose was to determine the prevalence of psychiatric symptoms for forty major psychiatric diagnoses including drug abuse and dependence. Based on the criteria for the marijuana dependence diagnosis utilized in that study (indications of tolerance or withdrawal plus pathological use or impaired social functioning lasting for at least one month), 4.4 percent of adults were found to have been dependent on marijuana at some point in their lives. About a decade later, interviews conducted with over 8,000 individuals for the National Comorbidity Study led to a very similar estimate that 4.2 percent of the general U.S. population meet the diagnostic criteria of marijuana dependence (Anthony, Warner, & Kessler, 1994).

For those who have used marijuana at least once, the relative probability of ever becoming dependent on the substance is estimated at 9 percent (Anthony, Warner, & Kessler, 1994). This risk level appears modest when compared with risk estimates of dependence for those who've used other substances at least once (tobacco-32%; alcohol-15%; cocaine-17%; heroin-23%). However, among individuals who have smoked marijuana more frequently, the risk of developing dependence is higher. Among those who've used it five or more times, the risk of dependence is 17 percent (Hall, Johnston, & Donnelly, 1999). For daily or near daily users, the risk may be as high as one in three (Kandel & Davies, 1992).

Treatment Approaches with Marijuana-Dependent Adults.

A series of controlled trials conducted since the mid-1980s have focused on evaluating interventions for marijuana-dependent adults. Stephens and Roffman (1994), in a 1986-1989 study funded by the National Institute on Drug Abuse, compared the effectiveness of a 10-session cognitive-behavioral group intervention with a 10-session social support group discussion condition. The cognitive-behavioral treatment focused on strengthening the participant's skills in effectively coping with relapse vulnerabilities. The social support treatment emphasized the use of group support for change. The participants were 212 marijuana smokers who averaged over ten years of near daily marijuana use. Following the completion of treatment and for the next 2.5 years in which participants were periodically reassessed, there were no significant differences between conditions in terms of outcomes (abstinence rates, days of marijuana use, problems related to use). During the final two weeks of counseling, 63 percent of the total sample reported being abstinent. While only 14 percent were continuously abstinent after one year, 36 percent had achieved improvement (i.e., either abstinence or reduction to 50 percent or less of the baseline use level and no reported marijuana-related problems) at that point. At 30 months post-treatment, 28 percent reported abstinence for the past 90 days. Thus, both counseling approaches were modestly effective in helping a significant portion of participants either achieve abstinence or improvement. These findings called into question the hypothesized superiority of a cognitive-behavioral approach with marijuana-dependent adults and argued for additional research on treatment approaches.

In a second NIDA-funded study conducted by Stephens and Roffman (1989-1994) with 291 adult daily marijuana smokers, a three-group design permitted the comparison of two active treatments with a delayed treatment control condition (Stephens, Roffman, & Curtin, in press). One of the active treatments involved 14 cognitive-behavioral skills training group sessions over a four-month period, emphasizing both the enhancement of coping capacities in dealing with situations presenting high risk of relapse and the provision of additional time for the building of group cohesion and mutual support. The second active treatment involved two individual motivational enhancement counseling sessions delivered over a one month period. The latter approach appeared promising inasmuch as a growing literature in the addiction treatment field was supporting the effectiveness of short-term interventions (Bien, Miller, & Tonigan, 1993), utilizing motivational interviewing strategies (Miller & Rollnick, 1991), designed to strengthen the individual's readiness to change (e.g., providing participants normative comparison data concerning their marijuana use patterns). The first session in this condition involved the counselor reviewing with the participant a written Personal Feedback Report generated from data collected during the study's baseline assessments. The counselor used this review as an opportunity to seek elaboration from the participant when expressions of motivation were elicited, to reinforce and strengthen efficacy for change, and to offer support in goal-setting and selecting strategies for behavior change. One month later, the second session afforded the opportunity to review efforts and coping skills utilized in the interim period. In both conditions, participants had the option of involving a supporter. Following treatment, there was no evidence of significant differences between the two active treatments in terms of abstinence rates, days of marijuana use, severity of problems, or number of dependence symptoms. At the 16-month assessment, 29 percent of group counseling participants and 28 percent of individual counseling participants reported having been abstinent for the past 90 days. Both active treatments produced substantial reductions in marijuana use relative to the delayed treatment control condition. The results of this study suggest that minimal interventions may be more cost-effective than extended group counseling efforts for this population.

The third study, funded by the Center for Substance Abuse Treatment (1996-2000) and conducted in three sites, also employed a three-group design with a delayed treatment control condition (Donaldson, 1998). One of the active treatments involved nine individual counseling sessions delivered over a 12-week period, with the initial sessions focusing on motivational enhancement and the later content emphasizing cognitive-behavioral skills training and, as needed, case management. The other active treatment involved two individual motivational enhancement therapy sessions delivered over a one-month period. (This condition replicated the brief intervention in the above-reported study conducted by Stephens and Roffman). At the 9-month follow-up, both active treatments produced outcomes superior to the 4-month delayed treatment control condition. Further, the 9-session intervention produced significantly greater reductions in marijuana use and associated negative consequences compared to the 2-session intervention. Abstinence rates at the 4- and 9-month follow-ups for the 9-session intervention were 23 percent and 13 percent, respectively. These differences between the two active treatments were apparent as early as 4 weeks into the treatment period and were sustained throughout the first nine months of follow-up. As was the case in the two studies discussed above, the findings of the CSAT-funded research point to modest efficacy of counseling interventions with marijuana-dependent adults. More positive outcomes from the 2-session motivational enhancement intervention were found in the Stephens and Roffman (in press) study than in the CSAT-funded investigation.

In a study funded by NIDA, Budney and colleagues randomly assigned sixty marijuana-dependent adults to one of three 14-week treatments: motivational enhancement, motivational enhancement plus coping skills training, or motivational enhancement plus coping skills training plus voucher-based incentives (Budney, Higgins, Radonovich, et al., in press). In the latter condition, participants who were drug abstinentdocumented with twice-weekly urinalysis screeningreceived vouchers that were exchangeable for retail items (e.g., movie passes, sporting equipment, educational classes, etc.). The value of each voucher increased with consecutively negative specimens. Conversely, the occurrence of a cannabinoid-positive urine specimen or failure to submit a sample led to a reduction of each voucher's value to its initial level. Participants in the voucher-based incentive condition were more likely to achieve periods of documented continuous abstinence from marijuana during treatment than were participants in the other two conditions. Additionally, a greater percentage of participants in the voucher-based condition (35%) were abstinent at the end of treatment than was the case in the skills training (10%) or motivational enhancement (5%) conditions. The absence of long-term post-treatment assessment data limits comparisons of this study's outcomes with those from the other trials discussed above. However, based on their earlier research with voucher-based incentives in treating cocaine-dependency, the authors are hopeful that future studies will demonstrate successful long-term outcomes in marijuana-dependent participants who achieve and maintain abstinence during treatment.

In reviewing the above work, it appears that some participants who sought treatment have been substantially aided in either quitting or cutting back. However, it is also apparent that the majority of those treated in the these studies reported above did not achieve their initial goal of durably abstaining from marijuana. Given the evidence of the drug's dependence potential and adverse health consequences (Hall, Johnston, & Donnelly, 1999), continuing development and testing of marijuana dependence interventions is clearly warranted.

Support Groups.

Marijuana Anonymous groups, a self-help fellowship based on the principles and traditions of Alcoholics Anonymous, exist in a number of states and internationally. In addition to in-person meetings, MA sessions are also held on-line. The organization's web site address is: www.marijuana-anonymous.org, and its toll-free telephone number is 800-766-7669.

User Characteristics Predictive of Treatment Success.

Stephens, Wertz, and Roffman (1993) reported predictors of successful outcomes in their first marijuana treatment trial. Higher levels of pretreatment marijuana use predicted higher use levels following treatment. Indicators of lower socioeconomic status predicted more reports of problems associated with marijuana use post-treatment. Finally, individuals who prior to treatment indicated greater self-efficacy for avoiding use had more successful post-treatment outcomes.

Reaching the Non-Treatment-Seeking Heavy Marijuana Smoker.

With funding from NIDA (1997 through 2000), Stephens and Roffman are conducting a clinical trial ("The Marijuana Check-Up") with 188 non-treatment-seeking adult marijuana smokers who have been randomly assigned to a motivational enhancement intervention (The Personal Feedback Session), a marijuana educational intervention (The Multimedia Feedback Session), or a brief waiting period. This study is adapted from a brief intervention ("The Drinker's Check-Up") in the alcoholism field (Miller & Sovereign, 1989).

In conducting The Marijuana Check-Up, a variety of recruitment strategies were used to attract participants, including posters, radio and newspaper ads, and outreach at various community events (Stephens, et al., 1998). Project publicity targeted adults over the age of 18 who used marijuana and had concerns or were interested in obtaining information. These strategies highlighted the objective, non-judgmental, and confidential approach of the study. All announcements emphasized that the MCU was not a treatment program. Those who inquired were told that although this program did not offer counseling for persons who wanted to quit or reduce their use, it would likely be useful in helping an individual better assess their experiences with marijuana.

The first MCU session involved a structured interview that included an assessment of the individual's use patterns, perceived benefits and adverse consequences associated with both continued use and reductions or cessation of use, and self-efficacy in accomplishing cessation. In the second session, feedback to the client from the initial assessment was largely normative and risk-related in nature. Utilizing motivational interviewing skills, the therapist elicited the client's views concerning benefits and costs associated with both his or her current marijuana use pattern, as well as various pathways of change. When appropriate, the discussion turned to goal-setting for reduction or cessation of use and the identification of useful behavior change strategies.

Based on the finding that 64 percent of participants met diagnostic criteria for cannabis dependence and, of those who did not, 89.4 percent met criteria for cannabis abuse (American Psychiatric Association, 1994), it was evident that the check-up modality offered a useful method for reaching the non-treatment-seeking heavy marijuana user. Upon joining the study, fewer than a third had resolved to quit or cut back on their use. They were using marijuana on more than 80 percent of the days prior to the interventions and typically getting high two or more times per day.

The check-up modality may also show promise in affecting behavior change. While the study is still ongoing, preliminary analyses of outcomes indicated that participants in the motivational enhancement condition (the personal feedback session) were more likely to both reduce the amount of marijuana smoked per day and the number of days of use than were those in the educational or wait-list control conditions.

Marijuana Withdrawal.

A mild syndrome of withdrawal from marijuana has been reported, with symptoms that may include: restlessness, irritability, mild agitation, insomnia, decreased appetite, sleep EEG disturbance, anxiety, stomach pain, nausea, runny nose, sweating, and cramping (Budney, Novy, & Hughes, 1999; Crowley, Macdonald, Whitmore, et al., 1998; Haney, Ward, Comer, et al., 1999; Jones, Benowitz, & Bachman, 1976). Commonly, these symptoms lessen within a week to 10 days.

The Future of Marijuana Interventions.

Currently underway or recently completed controlled trials testing various models of marijuana dependence treatment with adults and adolescents will undoubtedly contribute new information to what is currently known. The "leading edge" of such studies include counseling interventions in which contingency management components, variations in motivational enhancement strategies, brief and extended cognitive-behavioral therapies, treatments involving family members, and alternative dosages and distributions of counseling episodes are being evaluated.

The treatment of marijuana dependence may also ultimately be informed by knowledge of human biology. As an example, there is some evidence for the role of genetics in determining whether the marijuana user will become dependent. In a study of more than 8,000 male twins, genes were shown to influence whether a person finds the effects of marijuana use pleasant (Lyons, Toomey, Meyer, et al., 1997). Comparable findings were demonstrated for females (Kendler & Prescott, 1998). While factors in an individual's social environment clearly influence whether he or she ever tries marijuana, becoming a heavy user or abuser may be more determined by genetically transmitted individual differences, perhaps involving the brain's reward system. Research in this area may eventually identify individual risk factors for marijuana dependence that people can use in making decisions about their own use of this drug.

Finally, considerable evidence for a biological basis to marijuana dependence has accumulated since the identification of a specific cannabinoid receptor in the brain (Devane, Dysarz, Johnson, et al., 1988) and the discovery of anandamide, a compound that binds to and activates the same receptor sites in the brain as delta-9-tetrahydrocannabinol (THC), the active ingredient in marijuana. (Devane, Hanus, Breuer, et al., 1992). Subsequently, researchers discovered a cannabinoid antagonist, a compound that blocks anandamide action in the brain (Rinaldi-Carmona, Barth, Heaulme, et al., 1994). Taken together, these discoveries have made it possible to systematically study the effects of chronic exposure to marijuana. With greater understanding of the cannabinoid neurochemical system's physiology, the potential for developing and testing pharmacological interventions for marijuana dependence is advanced.

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Miller, W. R., & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press.

Miller, W. R., & Sovereign, R. G. (1989). The checkup: A model for early intervention in addictive behaviors. In T. Loberg, W. R. Miller, P. E. Nathan, et al. (Eds.), Addictive Behaviors: Prevention and Early Intervention (pp. 87-101). Amsterdam: Sweta & Zeitlinger.

Rinaldi-Carmona, M., Barth, F., Heaulme, M., et al. (1994). SR 141716A, a potent and selective antagonist of the brain cannabinoid receptor. FEBS Lett., 350, 240-244.

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Roger A. Roffman

Robert S. Stephens

Polydrug Abuse, An Overview

Polydrug abuse (also called multiple-drug abuse) refers to the recurring use of three or more categories of Psychoactive substances. It is a pattern of substance abuse that is most commonly associated with illegal drug use and youth. Most polydrug users also smoke Tobacco, but Nicotine has only recently begun to be recognized as a drug of abuse to be addressed with polydrug users.

While the term Polydrug User is usually reserved for people with a rather varied and nonspecific pattern of drug use, many drug users who have a preferred (a primary) drug of abuse are also poly-drug users. In fact, it is uncommon for users of any illicit drug to restrict their substance use to only the one drug. For example, an individual may be a regular Cocaine user but also use Alcohol, Tranquilizers, and Marijuana.

WITHDRAWAL

The intensity of withdrawal symptoms and their medical risk depends on the particular substances used and the degree to which dependence has developed. Withdrawal is most often clinically significant in those who have developed severe dependence on a primary drug of abuse; the medical risks of such withdrawal vary substantially with the type of drug. For example, much greater risks exist for Barbiturate than for Heroin withdrawal. The recent use of other drugs in addition to the primary drug of abuse complicates the withdrawal process. In such cases, careful medical assessment is important in the planning of withdrawal management for polydrug users.

Polydrug users who typically dabble among the available drugs without developing severe dependence on any of them usually have no clinically serious problems when they stop using drugs. They may experience some discomfort, agitation, or sleeplessness but they do not normally require medical treatment. Social stability and support would be important, however, as the risk of relapse could be high during this period of discomfort.

ASSESSMENT

There are two main purposes of assessment: (1) to determine what specific treatment would be most suited to the specific needs of the polydrug user; and (2) to determine baseline levels of functioning against which progress in treatment can be measured. Assessment must address many areas of functioning in addition to drug use. These include the following: medical and psychiatric problems; family and other social relationships; school or work problems; leisure activities and skills; criminal activities and legal problems; and financial status.

Drug use must be carefully assessed in the poly-drug user, because of the variety of drugs used and the need to evaluate the risks associated with the particular pattern of use. The usual procedure is to divide drug use into categories based on pharmacological similarities. These categories typically include: alcohol; marijuana; Hallucinogens (e.g., LSD); heroin; other Opioids (e.g., Codeine); cocaine; other Stimulants (e.g., Amphetamines); Tranquilizers (e.g., Benzodiazepines such as Valium) and other sedative hypnotics (e.g., barbiturates); and solvents (including glue). Because accurate estimates of doses are very difficult to obtain from polydrug users, their drug use is usually assessed as the number of times each drug has been used within a specified time period. Other important factors to consider in assessing drug use are risks related to Human Immunodeficiency Virus (HIV) infectionespecially injection drug use, and drugs used in combination.

A further consideration in assessment is the client's commitment to change. Polydrug users may be, at best, ambivalent about the need for change. The assessment process offers an excellent opportunity to enhance the polydrug user's motivation for change by providing feedback and support, as well as by helping the person to clarify goals and values.

TREATMENT APPROACHES

Many different treatment approaches are available, but they reflect differing conceptual or theoretical perspectives on the origins of drug-use problems as well as on the best ways to treat them. Most of these approaches were not developed for the polydrug user but, instead, were adapted from other substance-abuse treatments. The approaches described may be presumed to be quite widely available except where restrictions are noted. Research evidence concerning their comparative effectiveness for polydrug users is extremely limited.

Approaches Based on the Disease Concept.

According to one variant of the disease concept, alcoholism and drug addiction are incurable diseases. Those affected are considered unable to control their use of the substance, because of an allergiclike, biological reaction. This approach has only one solution to the problemto get the user to abstain from any use of the drug.

Twelve-Step Groups.

The treatment approaches most commonly associated with the disease concept are those based on Alcoholics Anonymous (AA), which was started in 1935. The Twelve-Step approach developed by AA has been adapted for application to other primary drugs of abuse, e.g., Narcotics Anonymous (NA) and Cocaine Anonymous (CA). Like AA, these approaches rely exclusively on self-help peer-group procedures. Members voluntarily embark on a lifetime journey of recovery, armed with a set of principles and the support of peers who share a common problem and a desire for change. The central features of these approaches are the following: an acceptance of being powerless over the drugs; a belief in a higher power; a commitment to make restitution to those who have been harmed; and personal responsibility to maintain abstinence. Polydrug users may affiliate with any of such groups, depending on the particular drugs most commonly used. They may, however, have some difficulty in identifying with the majority of group members as peers. Often a buddy or two with the same problems and concerns become a special subgroup.

Chemical-Dependency Programs.

Some treatment programs, most notably residential programs, have adapted the twelve-step approach as the basis of their treatment. Chemical-dependency (CD) programs are the most prominent example. These programs are an extension of the four week Minnesota Model (for Alcoholism) to a broader range of substances of abuse. Some have a particular focus for young polydrug users.

The CD approach usually involves a three- to six-week structured and intensive residential-treatment phase, which includes lectures and discussions about the harmful effects of drug use; group-therapy sessions that focus on breaking down denial and personal issues related to drug use; an orientation to the twelve-step approach; recreational and physical activity; and family counseling sessions. The residential phase is followed by an extended aftercare program, typically involving attendance at AA, NA, or CA meetings. Many CD programs specialize in the treatment of polydrug users who also have coexisting psychiatric problems.

The number of CD programs has grown rapidly in the past decade, particularly in private hospitals. Because of their residential phase, these CD programs are among the most expensive form of treatment available to polydrug users.

Systems Theory-Based Approaches.

Systems theory holds that individuals function within a variety of social systems (e.g., the family and peer groups) and that these systems act to influence behavior and to resist changes that are not in the interest of the broader system. From this perspective, drug use may be seen as serving some useful purpose within the "identified client's" social systems. Attempts to change that drug-use behavior without ensuring that the system will support and maintain such a change may be doomed to failure.

Family Therapy.

Family therapy is the most common application of systems theory to the treatment of polydrug users. This is because research has linked various forms of family dysfunction to the development of drug-use problems. Also, many polydrug users are children and young adolescents and their drug use is a major family issue.

In family therapy, the family rather than the polydrug user becomes the client. Treatment addresses family-system issues, which include family roles, patterns of communication, and structural factors such as the alliances that may exist within and among parts of the family system. The presenting problem of drug abuse may be dealt with directly within the framework of the family approach. It may otherwise be treated as a symptom of the family's dysfunctionwhere the expectation is that the drug use will disappear with resolution of the more fundamental family problems.

In family therapy, all or most of the family members typically attend the treatment sessions. One-person family therapy is a variation on this practice, in which the treatment focuses on changes to the family system via one member of that system. This practice is, however, very limited in comparison with the more common approach of involving most or all the other family members.

Peer-Network Therapy.

Peer-network therapy focuses on the peer or friendship social system. Poly-drug users are typically young and their drug use is often a social activity. Much research evidence links all drug use to peer associations. This may be caused by peer influence or because drug users seek out other drug users. Either way, it is widely believed that changes in peer associations are a necessary step for polydrug users who would attempt to discontinue drug use.

Peer-network therapy involves systematically examining the relationship of drug use to association with particular peers. Strategies involve avoiding certain peers; strengthening peer relationships in which drug use is not a factor; reestablishing old relationships that may have been ignored while drug use was occurring; using a buddy system to facilitate developing new peer relationships; and structuring leisure activities to help the client meet new friends who share similar attitudes and goals concerning drug use. Typically, changes in the peer system are introduced via the identified client, but peer-network therapy may also involve sessions that include other members of the peer network.

Peer-network therapy is still a relatively novel approach to the treatment of polydrug users, although many treatment programs are placing increased emphasis on changes to peer networks as part of their overall treatment strategy.

Peer Counseling.

Polydrug use is the most common pattern of substance abuse for many novice drug users. For such individuals, early intervention programs based on peer counseling, and provided in school or neighborhood settings, may be appropriate. Peer counseling capitalizes on the tendency for adolescents to be most influenced by their peers. Peer counselors are selected on the basis of their ability to act as good role models. They are trained to emphasize practical strategies to assist polydrug users to change their lifestyles in ways that support becoming drug free. They also act as facilitators or group leaders in peer counseling groups, in which adolescents learn from each other.

Social Learning Theory-Based Approaches.

Social learning theory suggests that drug use is a learned behavior and that it may be changed by the therapeutic application of principles of learning theory. Treatments based on social learning theory usually begin with a functional analysis of the drug use. This involves a detailed analysis of the circumstances in which drug use occurs and the apparent benefits to the user. The basic assumption is that drug use serves useful purposes (functions) in the life of the user and that understanding these functions of drug use is a critical step in planning treatment.

Coping Skills Training.

One such treatment approach is based on substituting alternative methods of obtaining the same benefits that drug use provides. If the individual becomes more sociable and outgoing on drugs, social-skill training is provided; if drug use reduces tension, stress-management techniques are offered. This approach is sometimes referred to as coping-skills training, because improved coping in one or more life areas usually becomes the primary treatment goal. Coping-skills training can address a variety of skill deficits from improved problem solving, to coping with depression, to increased assertiveness. The objective is to provide the polydrug user with alternative methods of coping with difficult life situations.

Since the 1970s, this type of approach has become the primary alternative to more traditional approaches based on the disease concept or psychotherapy.

Contingency Management.

Contingency management involves structuring unpleasant consequences to occur when drugs are used. The assumption is that these adverse consequences will compete with the benefits the user gets from the drug use, thereby reducing the likelihood that drug use will continue. Contingency management procedures are most effective when the occurrence of the drug use behavior can be reliably determined and the prescribed consequences reliably administered. Urine screening is the most common means of monitoring whether any drug use has occurred. Clients are typically required to provide urine specimens according to a random schedule that minimizes the opportunity to plan drug use to escape detection. A variety of types of consequences can be used. For example, clients may avoid the loss of a job, regain custody of children, or avoid breach of probation by consistently providing "clean" urines. While many treatment programs emphasize the consequences of drug use, few do so in the very systematic way required by contingency management.

Cue Exposure.

Cue-exposure techniques focus on the circumstances that precede or "cue" drug use. Frequent repetition of patterns of drug taking may result in certain cues becoming conditioned so that the user experiences cravings for the drug in the presence of these cues. For example, observing drug-use paraphernalia or being in a setting in which drugs have frequently been used in the past, may cause the polydrug user to experience cravings. These cues can be the cause of relapse. Treatment involves repeatedly exposing the individual to these cues in a controlled manner (e.g., with a supportive person present) until the cue no longer elicits the craving response. Conditioning is more apt to occur for a specific drug than across a variety of drugs. Hence cue exposure may be most relevant for polydrug users with a pronounced primary drug of abuse.

Approaches Aimed at Major Psychological Change.

These approaches assume that the cause of drug use lies in the psychological makeup of the polydrug user. From this perspective, drug use is a self-destructive or deviant act brought about by serious underlying psychological problems or the adoption of anti-social values. Treatment is aimed at correcting the underlying problem for which drug use is thought to be merely a symptom.

Psychotherapy.

Psychotherapy is an intensive and extended counseling approach in which the therapist explores the past events in the client's life with the aim of uncovering emotionally upsetting events or identifying themes or patterns of behavior that interfere with the effective social and psychological functioning of the individual. The drug use itself would seldom be the focus of the treatment sessions. Rather, the goal of psychotherapy would be psychological growth to change the personality of the polydrug user.

Psychotherapy can be provided on a one-to-one or group basis. It is typically provided on an outpatient basis but has also been provided within the framework of long-term residential programs for young drug users. Psychotherapy can be a comparatively expensive form of treatment, because it requires highly skilled therapists and typically takes longer to complete than other therapies. It may be most relevant when the polydrug user also has a psychiatric problem (e.g., depression).

Therapeutic Communities.

Therapeutic Communities (TC's) are long-term residential programs of twelve to twenty-four months duration. There are several types of TC, all of which share a common belief that clients gain from living together in a therapeutic environment for an extended period of time. The most prominent TC model is based on the Synanon program developed for heroin addicts in the late 1950s. Since that time, many variations of this model have evolved and the target treatment population has been broadened to include polydrug users.

The treatment approach is typically targeted to hard-core drug users who are judged to have serious personality deficits or chronic antisocial values. The problem is presumed to be the person, not the drug or the individual's social environment. The treatment is extremely intensive, often involving harsh confrontation and emotionally charged encounters. The intent is to break through the protective shell that the polydrug user has developedin response to past deprivations and abuseand to resocialize the individual to adopt new values and patterns of behavior. Consistent with its self-help origins, treatment within the TC is usually provided by recovered addicts.

Psychobiological Approaches.

Psychobiological approaches involve interventions which have a biological (often neurological) mechanism of action. Examples include treatments that involve the administration of a drug (pharmacotherapies) and Acupuncture, although the latter has had little application to the treatment of polydrug users. These approaches are based on the assumption that it is possible to change drug-use behavior by biological methods even though the drug-use problem may not have biological origins. For example, a drug may be used in treatment to eliminate the positive effects of an abused drug, thereby reducing the likelihood that its use will continue.

Pharmacotherapies.

Drugs are used in the treatment of substance-abuse problems for a variety of purposes. These include substituting for the drug effect; blocking or changing the drug effect; or treating a condition that is believed to underlie, or at least contribute to, the substance-abuse problem. Most pharmacotherapy approaches are intended to address the misuse of specific substances, which limit their application to polydrug users; however, many polydrug users have preferred drugs of abuse for which a pharmacotherapy approach may be appropriate. In such instances, it will usually be necessary to combine the pharmacotherapy treatment with some other approach to ensure that treatment addresses all the individual's drugs of abuse.

Methadone treatment is the best-known of the drug-substitution approaches. Methadone substitutes for heroin (and other opioid drugs) prevent the onset of withdrawal symptoms in addicts. This serves to stabilize the user with regard to the desire or need to continue heroin use until the addict develops sufficient confidence and a strong enough support system to become drug free.

Other drugs used in treatment (e.g., Naltrexone) act on the brain to block or reduce the pleasant sensations associated with the use of particular drugs. The assumption is that if the so-called beneficial effects of the drug are eliminated or reduced, it is less likely to be used. So-called anti-alcohol drugs (Antabuse and Temposil) take this notion one step further, by altering the metabolism of alcohol so that its effects become very unpleasant (the individual gets sick if alcohol is consumed while the drug is in effect). For all these approaches, strategies to ensure that the individual actually takes the prescribed drug are very important since the polydrug user can easily obtain the desired drug effects just by not taking the treatment drug.

Finally, some polydrug use reflects an attempt at self-medication to cope with symptoms of untreated psychiatric problems. The appropriate diagnosis and treatment (with medication) of such problems may reduce the client's need to self-medicate. Examples of this form of pharmacotherapy include medications for the treatment of anxiety, mood disorder, and psychotic disorders.

THE IMPORTANCE OF MATCHING TREATMENT TO CLIENT NEEDS

This chapter has described a broad range of treatment approaches available to the polydrug user. In practice, treatment programs often combine elements of the various approaches described. None of the approaches can claim general superiority over any other. Any one of them may be the most appropriate treatment choice for a particular individual under certain circumstances. It is important to assess the needs and wishes of the polydrug user carefully before selecting the treatment that seems most likely to be most helpful.

(See also: Addiction: Concepts and Definitions ; Adolescents and Drug Use ; Causes of Substance Abuse ; Comorbidity and Vulnerability ; Contingency Contracts ; Disease Concept of Alcoholism and Drug Abuse ; Methadone Maintenance Programs ; Prevention ; Treatment Types )

BIBLIOGRAPHY

Beschner, G. M., & A. S. Friedman (1985). Treatment of adolescent drug abusers. International Journal of the Addictions, 20 (6&7), 971-993.

Deleon, G., &D. Deitch (1985). Treatment of the adolescent substance abuser in a therapeutic community. In A. S. Friedman & G. M. Beschner (Eds.), Treatment services for adolescent substance abusers. Rockville, Maryland: National Institute on Drug Abuse.

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Wilkinson, D. A., & Garth W. Martin (1991). Intervention methods for youth with problems of substance abuse. In Helen M. Annis & Christine Susan Davis (Eds.). Youth and drugs: Drug use by adolescents: Identification, assessment and intervention. Toronto: Addiction Research Foundation

Garth Martin

Polydrug Abuse, Pharmacotherapy

Although many individuals present with abuse or dependence upon a single Psychoactive Substance, increasing numbers of drug users are presenting with dependencies upon two or more such substances. The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) and the International Classification of Diseases of the World Health Organization (ICD-10) define a condition called "polydrug dependence" or "multiple drug dependence," in which there is dependence on three or more psychoactive substances at one time. Polydrug dependence is particularly common among adolescents and young adults. However, if one includes Nicotine and Caffeine dependence, over half of patients with psychoactive-substance dependence are polydrug-dependent.

The use of specific, preferred combinations of drugs is typically seen in polydrug users. Opioids and Cocaine are often used together, as are Alcohol and cocaine or nicotine and alcohol. Alcohol, Benzodiazepines, and cocaine are often used together by opiate users, especially Methadone users. Illicit-drug users often show nicotine and caffeine dependence. Some individuals will use whatever psychoactive substances are available. One useful distinction is the difference between simultaneous and concurrent polydrug use. In simultaneous polydrug use, the drugs are used together at the same time for a combined effect, such as heroin and cocaine mixed and injected as a "speedball." In concurrent polydrug use, the various drugs are used regularly but not necessarily together. An example is a heroin user who uses benzodiazepines and alcohol to get another kind of high. In other cases, the polydrug abuser may self-medicate with one drug to offset the side effects of another. Cocaine abusers often take diazepam (Valium) to relieve the irritability that follows cocaine binges. Heroin addicts sometimes take benzodiazepines to relieve the anxiety that characterizes the early stages of opioid withdrawal. A more recent development is the abuse of antidepressant medications among heroin users. The tricyclics appear to be abused more frequently than either the SSRIs or the MAO inhibitors.

TREATMENT

The treatment of the polydrug user presents a particular challenge to the clinician. The simultaneous and concurrent use of multiple drugs may increase the level of dependence, increase drug toxicities, worsen medical and psychiatric comorbidities due to the drugs, and intensify withdrawal signs and symptoms upon cessation of drug use. The basic principles of treatment of polydrug use are similar to those for the treatment of any single psychoactive-substance dependence. Patients require a complete medical and psychiatric assessment, treatment of active problems, detoxification, then rehabilitation with attempts to reduce subsequent use of the drugs. One of the complications of treating polydrug users is that the patient's history may be unreliablemany cannot remember what they have used and others do not know the identity of drugs they have purchased on the street.

In providing treatment for the polysubstance user, there are two options: (1) sequential treatment for the dependencies, with initial treatment of the major dependency or the dependency with greater morbidity; or (2) simultaneous treatment of all dependencies. Unfortunately, few objective data exist as to which type of treatment is optimal for which patients. Most clinicians rely on their own experience, the capabilities of the treatment setting, and the wishes of the patient. One rule of thumb that has been suggested for complex detoxifications is to focus initially on the CNS depressant drug (s) and not be overly concerned with the opioid component. The patient can be stabilized with regard to the opioid with methadone, and given phenobarbital to prevent the potentially life-threatening symptoms of sedative withdrawal.

The treatment of polysubstance dependence often involves more than one type of treatment modality. A common example is an alcohol-dependent, opioid-dependent, cigarette smoker who is receiving Methadone Maintenance for opioid dependence, abstinence-oriented treatment for alcoholism, and no specific treatment for nicotine dependence. The different treatment philosophiesmethadone substitution, abstinence, and no treatmentnecessarily conflict. In such cases, good communication and flexibility among the various treatment providers and with the patient are important to ensure optimal, coordinated treatment.

DETOXIFICATION

During the initial treatment of polysubstance abuse and dependence, the primary goals include cessation of substance use and the establishment of a substance-free state. If necessary, detoxification occurs, as well as management of medical and psychiatric problems. Detoxification is the removal of the drug in a fashion that minimizes signs and symptoms of withdrawal. It can be pharmacological or drug free. Pharmacological methods for detoxification include (1) a slow decrease in the dose of the drug or of a cross-tolerant agent (e.g., methadone for heroin withdrawal, diazepam for alcohol withdrawal, Nicotine Gum for smoking cessation) and (2) stopping the drug and using an alternative agent to suppress signs and symptoms of withdrawal (e.g., Clonidine for opioid withdrawal, atenolol for alcohol withdrawal). For many drugs, pharmacologically assisted detoxification is not necessary. Simple alcohol withdrawal can be treated with supportive care. However, the presence of polysubstance dependence usually increases the need for pharmacological agents to assist in withdrawal.

There are few controlled studies on the clinical course and optimal therapies for detoxification from multiple psychoactive substances. Patients can be detoxified from all psychoactive substances together, or maintained on one or more drugs while being detoxified from others. When the drugs used are all part of the same class (e.g., alcohol and sedatives; methadone, Codeine, and heroin), a complete detoxification is more common. When the drugs used are from different classes, partial or sequential detoxification usually occurs. An example of the latter situation is an opioid, cocaine, alcohol, and nicotine user who is detoxified from alcohol and cocaine, but maintained on methadone and allowed to continue tobacco use. Sometimes a partial detoxification is indicated because of the need for continued psychotropic medication for medical or psychiatric illnesses, such as continued opioids for chronic pain or benzodiazepines for anxiety.

Given the cross-tolerance of most Sedative-Hypnotics with ethanol, methods that are effective for the detoxification from alcohol or sedatives alone are usually effective for the combinations of alcohol and sedatives. Loading techniques, with long-acting benzodiazepines, such as diazepam or Chlordiazepoxide, or with Barbiturates, such as Phenobarbital, are well documented as effective. The advantages of these methods include matching the medication used for withdrawal to the individual patient's tolerance and the avoidance of overmedication. The anticonvulsant carbamazepine (Tegretol) has been shown to be effective for the treatment of combined alcohol and sedative withdrawal.

Although the mechanisms of action of various drugs differ, there are common neurological substrates of certain behavioral effects and of withdrawal signs and symptoms. The autonomic hyper-activity and some of the CNS excitation common to several withdrawal syndromes are mediated by the locus ceruleus of the brain. Medications such as alpha-2 antagonists (clonidine) and benzodiazepines, which inhibit locus ceruleus activity, have been shown to attenuate the symptoms of nicotine withdrawal. However, clonidine will not block the seizures that result from alcohol or sedative withdrawal.

LONG-TERM TREATMENT

In the long-term phase of treatment, the patient undergoes rehabilitation and reestablishment of a lifestyle free of drug dependency. Pharmacological treatment is sometimes used to assist rehabilitation. Pharmacotherapies may reduce drug craving, decrease protracted withdrawal symptoms, or decrease positive reinforcing effects of the drugs. Types of pharmacological therapies used in long-term treatment and rehabilitation include (1) maintenance (e.g., methadone maintenance for the treatment of opiate dependence); (2) blockade (e.g., Naltrexone treatment for opioid dependence); (3) aversive therapy (e.g., Disulfiram for alcoholism, possibly naltrexone for alcoholism); and (4) psychotropic drug treatment of coexisting psychiatric disorders, such as lithium for bipolar alcoholics, or methylphenidate for cocaine-dependent patients with Attention Deficit Disorder.

The use of pharmacological agents as adjuncts in the treatment of polysubstance dependence is an area of active investigation. One medication that may prove useful in the treatment of combined cocaine and opioid dependence is buprenorphine (Buprenex). This partial mu agonist, used as a surgical analgesic, has shown efficacy as a substitute in the long-term treatment of opioid dependence. Compared with methadone, buprenorphine may produce less dependence and fewer withdrawal symptoms upon cessation. Buprenorphine treatment also may reduce cocaine use in some individuals dependent on both opioids and cocaine. Animal studies of the effects of buprenorphine on "speedball" self-administration are consistent with the findings of clinical trials of buprenorphine in polydrug abusers. Other research suggests that buprenorphine is effective in patients dependent on both cocaine and heroin because it improves regional cerebral blood flow. Desipramine has been reported as being effective in reducing cocaine use in methadone patients. Disulfiram, which is efficacious in the treatment of alcoholism, may also reduce cocaine use in individuals using both alcohol and cocaine.

Newer pharmacological agents that are being investigated for possible use in long-term treatment of polydrug abuse include a medication mixture of flupenthixol, a dopamine antagonist, and quadazocine, an opioid antagonist. The mixture targets combined stimulant/opioid abuse. A combination of these two drugs appears to be more effective in treating combined abuse of heroin and cocaine than either antagonist alone. Another agent that may have therapeutic potential is gamma-hydroxybutyric acid, a compound that affects the brain's dopaminergic systems. It may also be a neurotransmitter. Gamma-hydroxybutyric acid, first used as an anesthetic, emerged as a drug of abuse around 1990. It is still used by bodybuilders, partygoers at "rave" dances, and polydrug abusers. As of 2000, preliminary evidence supports its use in the treatment of alcohol and opiate dependence.

(See also: Comorbidity and Vulnerability ; Treatment-Treatment Types )

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Robert M. Swift

Revised by Rebecca J. Frey

Tobacco, An Overview

Ever since tobacco use became popular, some users have been trying to quit. Sometimes they sought treatment because the tobacco was too expensive, because companions complained about the tobacco use, because they did not like the smoke in the air, or, in the case of Smokeless Tobacco (chewing tobacco or spitting snuff), because they did not like the tobacco juice on the floor. Sometimes treatment was sought out of concern for health problems.

Cigarette smoking is the most common form of tobacco use, and smoking is one of the nation's most critical public health problems. Tobacco use causes more than 430,000 deaths each year in the United States and is the leading preventable cause of death. Most adults in the United States have either smoked cigarettes or used some other tobacco product. In 1997, 71 percent of the population aged twelve or older had tried cigarettes at some time in their lives. This article focuses on the treatment of cigarette smoking but will include a brief discussion of the treatment of smokeless tobacco use, for which many of the same principles apply.

According to the Surgeon General's report on reduction of tobacco, existing types of smoking intervention can be used to reduce smoking. Researchers believe that widespread dissemination of the approaches and methods shown to be effective, especially in combination, would substantially reduce the number of young people who will become addicted to tobacco, increase the success rate of young people and adults trying to quit using tobacco, decrease the level of exposure of nonsmokers to environmental tobacco smoke, reduce the disparities related to tobacco use and its health effects among different population groups, and decrease the future health burden of tobacco-related disease and death in this country.

There are a number of different methods used in the treatment of nicotine addiction. Behavioral counseling and nicotine replacement therapy have proven the most effective forms of intervention for nicotine addiction, particularly when they are combined. Non-nicotine medications, such as antidepressants, anxiolytics, and nicotine antagonists, are among the medications also used in treatment, though their efficacy is still under investigation.

TRENDS IN SMOKING CESSATION

Although the prevalence of smoking among the American public decreased in the late 1900s, the current number of smokers is still substantial. In the late 1990s, about one-quarter of adult Americans, or about 48 million people, smoked. Most of these people wanted to quit but were unable to do so because they found it too difficult. According to some figures from the late 1990s, only an estimated 2.5 percent of all smokers successfully quit each year.

EFFECTS OF SMOKING CESSATION

There are a number of physiological effects that take place in the human body after cessation of smoking. About twenty minutes after cessation, the blood pressure and pulse rate return to normal, and the body temperature increases to normal. About 8 hours later, the carbon monoxide level in the blood drops to normal, and after 1 day, an individual's chance of a heart attack decreases. After two days, nerve endings start to regenerate, and the ability to smell and taste is improves. After two weeks, an individual's circulation improves and the functionality of the lungs increase by a maximum of 30 percent. After a year of smoking abstinence, the risk of coronary heart disease is reduced to half that of a smoker, and after five years of cessation, the risk of death by lung cancer is cut in half. After fifteen years, the risk of coronary heart disease is equal to that of a nonsmoker.

RESEARCH ON CESSATION OF TOBACCO USE

Although the scientific study of smoking treatments dates from the mid-1900s, "nonscientific" and "scientific" treatments often overlap. Until the 1980s, there were still many observers who doubted that tobacco use was based on an addiction to or dependence on nicotine. In the 1950s and 1960s, many experts believed that smoking was "just a bad habit." Experts at that time failed to appreciate that tobacco use was a form of drug use; instead, they saw smoking as the kind of habit that could be broken by taking certain behavioral steps. This attitude was the origin of the so-called behavioral techniques for stopping smoking.

In the early part of the twentieth century, self-help movements were very popular and were directed against alcohol and other drug problems. Such efforts at behavioral changes have a long history in society. Perhaps because they are so commonplace, people tend not to seek professional help for dealing with minor behavioral problems. As a result, it should not be surprising that over the years much of the "treatment" for cigarette smoking has been self-administered. However, researchers find that self-help treatments have not generally been proven effective for most people. In one study of 5,000 smokers, only 4.3 percent of individuals who had quit on their own remained abstinent for one year after they attempted to quit. Self-help treatments, combined with such intensive treatment as behavioral counseling, nicotine replacement, or the combination of the two, is likely to be more effective.

No single treatment stands out as being the single best way for all smokers. In general, however, researchers have found that nicotine replacement therapy combined with behavioral counseling has shown the best results in the treatment of nicotine addiction.

GROUP VERSUS INDIVIDUAL THERAPIES

Much of the instruction and support that is part of smoking treatment can be done individuallyone-on-onewith clients or can be delivered to a group of clients. Group programs have been used to provide hypnotism, educational therapies, behavioral therapies, and combined therapies. There is no clear scientific evidence indicating which delivery system is best, but it is clear that group programs can be less expensive than individual programs and that some clients have strong personal preferences for how they wish to receive treatment: Some enjoy the group support and like to share their experiences in a group; others find such involvement with groups unpleasant or embarrassing. As for the efficacy of such therapies, researchers have found that the more time counselors spend with smokers in a treatment session, the higher the likelihood of cessation. Longer duration of treatment in weeks and the total number of treatment sessions is also associated with improved odds of smoking cessation.

PHYSICIAN-BASED TREATMENTS

Physicians interested in preventive medicine make special efforts to encourage and support smoking cessation in their patients. In 1964, only about 15 percent of current smokers reported that a physician had advised them to quit smoking. By 1987, about 50 percent of current smokers had received such advice. Sometimes just the advice of a physician to quit and the setting of a quitting date can lead to successful smoking cessation. Physicians can also be helpful by referring patients to smoking treatment programs. Specialists who deal with patients already suffering from a smoking-related disease can be in a good position to help those who are well motivated to quit, but cardiac or lung patients often fail to stop smoking. Being diagnosed with a smoking-related disease is no guarantee that the patient will quit smoking.

The Importance of "Minimal" Interventions.

In medical settings, there has been research on the value of interventions (e.g., brief advice, pamphlets) that take only a few minutes of the physician's time. Although the effects of these interventions are usually small, they are generally viewed as worthwhile because they can reach so many smokers.

SMOKING CESSATION EFFORTS BY AGENCIES

Many diseases caused by smokingcancer, heart disease, lung diseasehave agencies concerned with furthering research, dissemination of public health information, and treatment of the disease. The Cancer Society, the Lung Association, and the Heart Foundation are voluntary, charitable organizations. Each has developed materials and programs to promote smoking cessation. The measured treatment effects of simple stop-smoking pamphlets are small, but since they can reach many smokers at very low cost, they should be viewed as beneficial elements of the public-health efforts to support smoking cessation. U.S. government agencies concerned with smoking and smoking-related disease have also developed and promoted materials and procedures to foster smoking cessation.

The voluntary agencies have supported smoking cessation efforts in the workplace, by providing smoking-treatment services and by promoting smoking bans in the workplace. Employee Assistance Programs (EAPs) increasingly offer help to smokers who are trying to quit. In addition to workplaces, many public places, such as restaurants and other public buildings, now prohibit smoking on their premises. Just as social pressures encouraged many smokers to start the habit, social pressures might encourage them to stop. Once it was fashionable to be a cigarette smoker; now it is becoming fashionable to stop smoking.

NICOTINE-REPLACEMENT THERAPIES

Nicotine-replacement therapies can help reduce the nicotine withdrawal symptoms after smoking cessation. Replacement therapies help individuals deal with their smoking gradually by separating the behavioral and pharmacological components of smoking. While physical symptoms of nicotine withdrawal are reduced, the individual can focus on dealing with the behavioral challenges of stopping. The most commonly used nicotine-replacement therapies are a gum that releases nicotine as it is chewed and a patch that slowly releases nicotine into the body through the skin. These therapies are available over-the-counter. Transdermal nicotine patches appear to be preferred by individuals over nicotine gum. They seem to have the fewest side effects and are associated with the greatest long-term abstinence rates.

Nicotine nasal sprays and nicotine vapor inhalers that deliver nicotine through the respiratory system are less common forms of nicotine-replacement therapy. They became available in the United States in 1996 and 1998, respectively. There have been reports of eye, nose, and throat irritation with the nasal sprays, but individuals have been known to build a tolerance to these effects.

Nicotine-replacement therapy is considered an effective treatment for smoking cessation, although the efficacy of the different methods varies when used alone. In addition, a number of negative side effects could potentially interfere with a patient's success with the therapy.

OTHER DRUGTHERAPIES

For someone who has tried repeatedly and yet failed to stop smoking for good, a medicine that could take away the desire to smoke would be welcome. A number of non-nicotine medications have been developed to help aid smokers in the cessation process. Nicotine antagonists help cut down on nicotine withdrawal symptomsincluding irritability and anxietyor mimic the effects achieved by smoking and thus may help decrease an individual's desire for a cigarette. Such antagonists include antidepressants, anxiolytics, and stimulants or anorectics. Other medications make smoking distasteful to the user. Studies on the efficacy of such non-nicotine drug therapies continue.

HYPNOSIS

Hypnosis is worth special mention because of its popularity as a smoking therapy. Careful evaluations of hypnotherapies show small or no treatment effects. One of the problems in studying hypnotherapies is that the actual hypnotic procedures involved are not standardized. The kind of procedures used and suggestions made to the hypnotized patient (e.g., "You will not want a cigarette" vs. "The thought of a cigarette will make you feel sick") differ from therapist to therapist. It is important to deal with reputable therapists who charge reasonable fees for their services.

MULTIMODAL THERAPIES

A wide range of behavioral therapies have been tested, and no single method stands out as particularly effective. Multimodal approaches have become widely used, in hopes that something loaded into the shotgun will hit its mark. Currently, there is no reliable way to judge beforehand which smoker will be most helped by a particular technique (the exception being that heavier, more dependent smokers are consistently more likely to benefit from nicotine replacement). The multimodal, something-for-everyone approach is reasonable. There is not room in this article to discuss in detail the variety of behavioral therapies that have been used, but they have in common the use of basic psychological principles of learning.

Contingency contracting involves, for example, the preparation of detailed contracts that spell out punishments that will follow from the return to smoking (e.g., if the patient relapses, he or she will give $100 to someone he or she dislikes).

Aversive conditioning procedures (e.g., rapid smoking, satiation) cause cigarette smoking to be associated strongly with the acute unpleasant effects (such as dizziness and nausea) of smoking very heavily.

Relapse Prevention and the Maintenance of Abstinence.

Relapse Prevention programs have been developed to reduce the problem of relapse or return to smoking. Many of the same behavioral techniques used in multimodal programs are applied to the task of helping prevent relapse and helping prevent the occasional slip back to smoking from becoming a permanent return.

Smoker's Anonymous Programs.

Smokers have sometimes organized this type of program to support smoking cessation. The program allows smokers to support each other and teach each other techniques that will help them to stop smoking and to keep from returning to smoking. These programs have not generally become popular. This is in contrast to the great popularity of Alcoholics Anonymous (AA) groups.

RELATION TO TREATMENT OF OTHER DRUGPROBLEMS

Heavy smoking is strongly linked to heavy alcohol and other drug use. Smoking is often found in those with Alcohol and other drug problems. Those smokers who fail to stop smoking may have serious alcohol or other drug problems that require treatment before the smoking problem can be resolved.

ON SELECTINGA WAY TO STOP SMOKING

Smokers should be advised to take a long view of their efforts to stop smoking, understanding that if one method does not help them, they should try another, and another, until they have stopped smoking. Any one attempt to stop smoking can meet with poor success. With repeated attempts, the smoker may encounter some success. Also, repeated attempts give the smoker experience with assorted treatment techniques, so that the individual begins to learn for what helps and what does not help. Finally, there may be a kind of "no more nice guy" effect, so that the smoker gets fed up with failing to quit smoking.

It is also important to realize that no two programs are delivered in exactly the same way. The individual characteristics of a therapist and the client's rapport with that therapist can contribute to a therapy's success. The person who wants help to stop smoking should investigate available community resources; the library is good place to start. If the first attempt fails, additional attempts should be planned.

A NOTE ON SMOKELESS TOBACCO

To the extent that chewing tobacco and dipping snuff can cause nicotine to be delivered to the brain in sufficient doses, they present a similar risk of nicotine dependence in the regular user. These products may prove more difficult to treat than cigarette use, because they are sometimes viewed as less risky alternatives to cigarettes. One study quoted in a Surgeon General's report on smoking reported that 77 percent of youth thought that cigarette smoking was very harmful, but only 40 percent rated smokeless tobacco as very harmful. Once the "negative publicity" on smokeless tobacco use reaches a level close to the bad press on smoking, there should be a growing demand for using the smoking therapies as treatments for the use of smokeless tobacco.

In addition to the problems associated with nicotine addiction, smokeless tobacco can cause bleeding gums and sores of the mouth that never heal. It is also associated with cancer. Smokeless tobacco also stains the teeth a dark yellow-brown color, gives the user bad-smelling breath, and can cause dizziness, hiccups, and vomiting in the individual. A further risk associated with smokeless tobacco is that youth who use it are more likely to try smoking than those who do not use it.

(See also: Addictions: Concepts and Definitions ; Nicotine Delivery Systems for Smoking Cessation ; Tobacco: Treatment Types )

BIBLIOGRAPHY

Cinciripini, P. M., Mc Clure, J. B. (1998). Smoking Cessation: Recent Developments in Behavioral and Pharmacologic Interventions, Oncology, 12.

Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (2000). Monitoring the Future national survey results on drug use, 1975-1999 Volume I: Secondary school students (NIH Publication No. 00-4802). Rockville, MD: National Institute on Drug Abuse.

Schwartz, J. L. (1987). Review and evaluation of smoking cessation methods: The United States and Canada, 1978-1985. Washington, DC: Division of Cancer Prevention and Control, National Cancer Institute.

U.S. Department of Health and Human Services. (1990). The health benefits of smoking cessation: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services. (1989). Reducing the health consequences of smoking: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services. (2000). Reducing tobacco use: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services. (1988). The health consequences of smoking: Nicotine addiction: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health, Education and Welfare. (1979). Smoking and health: A report of the surgeon-general. Washington, DC: U.S. Government Printing Office.

Lynn T. Kozlowski

Revised by Patricia Ohlenroth

Tobacco, Pharmacotherapy

Although tobacco use causes a powerful addiction, people who want to stop using it can be helped, and at far less expense than treatment of tobacco-caused diseaseswhich will kill approximately one in two smokers who do not quit. The effort to find pharmacological agents that would help tobacco users quit is not a new development. In the late 1890s and early 1900s, a number of potent medicines were advertised as being useful for reducing tobacco craving and helping break the habit. Such advertising was possible because at the time there were no regulations requiring a seller to demonstrate that the product was effective. None of the products offered to the public between the early 1900s and the late 1970s were demonstrably better than placebos in helping smokers quit. Effective pharmacological approaches to treating nicotine addiction, including transdermal patches that deliver nicotine through the skin, and resin complexes (gum) that release nicotine when chewed, were among the important medical advances of the 1980s and 1990s. To understand how pharmacotherapy works, it is necessary to understand the role of Nicotine in the addiction to tobacco.

Nicotine is a naturally occurring alkaloid present in the tobacco leaf. It is a small lipid and water-soluble molecule, rapidly absorbed through the skin and mucosal lining of the mouth and nose or by inhalation in the lungs. In the lungs, nicotine is rapidly extracted from tobacco smoke within a few seconds because of the massive area for gas exchange in the alveoli; it is passed into the pulmonary veins, and pumped through the left ventricle of the heart into the arterial circulation within another few seconds. Within 10 seconds, a highly concentrated bullet (bolus) of nicotine-rich blood reaches organs such as the brain as well as the fetus of a pregnant woman. Arterial blood levels may be ten times higher than venous levels within 15 to 20 seconds after smoking. Nicotine arterial boli from smoking a single cigarette may be three to five times more concentrated than the low, steady levels obtained from nicotine gum or patch systems. These spikes probably contribute to the pleasure sought by the cigarette smoker, but, fortunately, they are not necessary to relieve withdrawal symptoms. Nicotine Gum and patches, which provide more steady nicotine levels without arterial spikes, may selectively relieve withdrawal without the highly addictive nicotine spikes produced by cigarettes. Although Smokeless Tobacco users do not obtain the same rapid nicotine increase as smokers, they may, by repeatedly putting new "pinches" in their mouths, achieve stable nicotine levels higher than those typical of smokers.

Most cigarettes on the U.S. market contain 8 to 9 milligrams (mg) of nicotine, and the average smoker obtains 1 to 2 mg per cigarette. In general, the type of cigarette or nicotine delivery rating reported by the manufacturer bears almost no relation to the level of nicotine obtained by the typical smoker, because smokers may change their behavior to compensate for differences in cigarette brands. For example, they may take additional puffs on low-nicotine brands.

Cigarette smoking produces rapid and large physiological changes, but, to a lesser extent, smokeless tobacco produces similar effects. Nicotine gum and patch treatments have the advantages of much slower nicotine delivery, and they produce less severe physiological changes. This slower delivery rate may be less pleasurable to the tobacco user, but the user is less likely to have difficulty giving up the gum or the patch after treatment.

Tobacco-caused cancer may be considered a side effect of nicotine dependence in much the same way that Acquired Immunodeficiency Syndrome (AIDS) may occur as a side effect of heroin dependence. In both cases, the exposure to the disease-causing toxins or to HIV occurs repeatedly and often frequently because individuals are dependent on a drug that has reduced (if not nearly eliminated) their ability to abstain from the highly contaminated drug delivery system they know may lead to disease and premature death.

The physiological basis of drug dependence became increasingly well understood in the past few decades and especially with regard to nicotine dependence in the 1970s and 1980s. Awareness of the physiology of nicotine dependence can help researchers understand the problems faced by people attempting to give up tobacco and can provide a more rational basis for the development of treatment programs that may prevent the occurrence of cancer and other diseases or contribute to remission in people who have been treated for cancer.

Tolerance as a result of repeated nicotine exposure is a crucial factor in the development of lung and other cancers. Essentially, smokers self-administer much greater amounts of tobacco-delivered toxins than would be the case if they had not developed tolerance. In turn, with development of nicotine dependence, smokers come to feel normal, comfortable, and most effective when taking the drug and to feel unhappy and ineffective when deprived of the drug. This process makes it more difficult to achieve and sustain even short-term abstinence.

PHARMACOLOGICAL TREATMENTS

Most smokers have quit on their own or, rather, tried to quit. Although 18 million try each year, less than 7 percent do so successfully. Most of the efforts were "cold turkey," good for a start, but the least effective of all techniques. Long-term abstinence rates are low for people using this method. Treatment programs are helpful in increasing rates of success, and the availability of pharmacological interventions gives clinicians additional useful tools to help the smoker. The major pharmacological approaches are nicotine replacement, symptomatic treatment, nicotine blockade, and deterrent therapy. Nicotine replacement and symptomatic treatment have become part of general medical practice. Until further information is collected, blockade and deterrent therapy must be considered experimental.

Nicotine Replacement.

The rationale for nicotine replacement is to substitute a safer, more manageable, and, ideally, less addictive (more easily discontinued) form of an abused drug to alleviate symptoms of withdrawal. An example of a less-addictive substitute is Methadone Maintenance for opiate abusers. Various forms of nicotine replacement have been developed including polacrilex (gum), transdermal delivery systems (patches), nasal vapor inhaler, nasal nicotine spray (gel droplets), and smoke-free nicotine cigarettes. The forms provide different doses and speeds of dosing. These parameters may be important in offering the smoker levels of nicotine necessary to alleviate withdrawal and cravings for nicotine. Currently, only the nicotine gum and patch are approved for use in the United States.

Several advantages exist in replacing nicotine from tobacco with non-tobacco-based systems such as gum or patches. First, they do not contain all the toxins present in tobacco or produced by burning tobacco. Second, total daily nicotine administration is lower for most patients on nicotine-replacement systems, and the high initial nicotine bolus doses produced by inhaling are not delivered. Third, the clinician can control doses more effectively than with tobacco-based products. The patient cannot, for example, take a few extra puffs per cigarette and defeat the purpose of gradual nicotine-reduction plans.

Nicotine gum may not be absorbed well if the client does not follow directions carefully. From 1984 until 1991, about 1 million prescriptions for nicotine gum, the only form of nicotine replacement then available, were filled per year. At the end of 1991, nicotine patches were introduced, and approximately 7 million prescriptions were filled for all replacement systems, with the nicotine patch accounting for nearly 90 percent of new prescriptions for nicotine replacement. The popularity of the nicotine patch can be measured by the higher rate of compliance than for the only currently available alternative, nicotine gum. Nicotine gum compliance rates tend to be lower because patients may dislike the taste and experience slightly sore mouths, throats, and jaws and gastrointestinal upset. Nevertheless, a study at the Addiction Research Center of the National Institute on Drug Abuse (NIDA) found nicotine gum to be effective in treating the cognitive function and corresponding brain electrical function changes of tobacco withdrawal. The effect was stronger at higher dose levels (e.g., 4 mg; see Figure 1). Because of current prescribing practices, this section will concentrate on the nicotine patch.

Four brands of nicotine patch are currently available in the United States. All deliver a given dose of nicotine transdermally, through the skin, over either a 24-hour (Habitrol, Prostep, and Nicoderm) or a 16-hour (Nicotrol) period. No clinical study has directly compared the four brands, but there is no evidence that any one brand leads to consistently higher rates of abstinence than any other. Variations in nicotine-delivery rate and skin contact effects may mean that certain patches work better for some people than others, but there is as yet no way to tell which patch will work better for an individual patient.

The nicotine patch is highly effective, resulting in an overall doubling of smoking cessation rates. Different studies have reported cessation rates of between 22 percent and 42 percent after six months of use. The combination of intense counseling and patch use was associated with higher success rates.

Work is necessary to develop a list of characteristics of those patients most likely to benefit from nicotine patch use. The University of Wisconsin's Center for Tobacco Research and Intervention suggests that patients may benefit if they are motivated to quit and fit into at least one of the following categories:

Smoke at least 20 cigarettes per day

Smoke first cigarette within 30 minutes of awakening

Have experienced a strong craving for cigarettes during the first week of previous attempts at quitting

The nicotine patch should be applied as soon as the patient awakens, and the user should stop all smoking during patch use. The patch should be applied to a hairless part of the body, with a different site every day. The same site should not be used again for one week. Side effects include a local skin reaction at the patch application site in 30 percent of patients and possibly sleep disruption. Because the tobacco-withdrawal syndrome also may include sleep disruption, it is sometimes difficult to determine whether the sleep disturbance is a result of tobacco withdrawal or nicotine patch therapy.

The four patches vary in their recommendations for length of treatment, from six to sixteen weeks. Because no published studies have documented a benefit for longer treatment, some researchers recommend 6 to 8 weeks for most patients, but therapy should be individualized where appropriate. Other researchers have concluded that, in general, the chances of success appear better in longer-term use.

In patients with cardiovascular disease, the nicotine patch may be used cautiously, although there has been no documented association between patch use and acute heart attacks. It should be used in pregnant patients with cautiononly after they have failed to quit using nondrug means. Nicotine replacement should not be given to people who continue to smoke, although the advisability of terminating therapy if only occasional cigarettes are smoked is subject to debate.

Nicotine delivered by tobacco products is one of the most highly addictive substances known. Even people highly motivated to quit may have profound difficulty doing so on their own. It is now known that people differ greatly in the severity of their addictions and their ability to cope. Our ability to treat nicotine addiction is continually improving. Even so, many people will require several repeated quitting attempts, regardless of treatment used. Therefore, long-term support by public health organizations and other facilities is essential if we are to prevent the serious diseases that will affect one in two untreated smokers.

Recent data from the 3 million people treated with the nicotine patch during its first seven months of availability in the United States increase optimism that the body can repair much of the damage caused by smoking. Epidemiological data indicate that 2,250 heart attacks would have occurred if these smokers had continued their habit. In fact, the Food and Drug Administration (FDA) received reports of only 33 severe cardiovascular problems. Even assuming underreporting, this decrease is so profound that it strongly supports the conclusion of the surgeon general in 1991 that risk of heart attacks rapidly declines after smoking cessation. These people were receiving nicotine via the patch, although probably at a lower level than if they continued smoking, and still their rate of heart attacks was significantly reduced.

Symptomatic Treatment.

Nicotine administration and withdrawal produce a number of neurohormonal and other physiological effects. Symptomatic treatment methods are nonspecific pharmacotherapies to relieve the discomforts and mood changes associated with withdrawal. If the potential quitter relapses to escape the suffering of withdrawal, these methods should help to prevent such relapse. There is a long history of pharmacological treatment of smokers. To reduce withdrawal, sedatives, tranquilizers, anticholinergics, sympathomimetics, and anticonvulsants have all been tried at one time and were no more successful in helping smokers quit than was a placebo. Clonidine is one agent that has been tried in the treatment of nicotine withdrawal discomfort and is commonly used to treat opioid withdrawal. Glassman and his colleagues (1984; 1988) administered clonidine to heavy smokers on days they abstained from smoking and found that it reduced anxiety, irritability, restlessness, tension, and craving for cigarettes. When they gave clonidine to smokers trying to quit, 6 months later, 27 percent of those given clonidine and 5 percent of those given placebo reported abstinence. Surprisingly, clonidine seemed to be effective only for women. Among men, those given clonidine did no better than those given a placebo. Before recommending clonidine for smokers, practitioners should consider potential side effects. Clonidine has been used to treat hypertension, and abrupt termination has sometimes led to severe hypertension and in rare circumstances to hypertensive encephalopathy and death. More commonly, it may cause drowsiness, potentially dangerous to someone operating machinery or driving.

Among nicotine's effects is the regulation of mood. Smokers have been shown to smoke more than usual during stressful situations; therefore, those trying to quit often relapse (begin smoking again) during stressful situations. These observations suggest that treating the mood changes associated with abstinence with, for example, Benzodiazepine tranquilizers, Antidepressants, or psychomotor stimulants may improve abstinence rates. The benzodiazepine tranquilizer alprazolam was also examined by Glassman and his colleagues (1984; 1988) and found to reduce anxiety, irritability, tension, and restlessness, but it had no effect on cravings for cigarettes in heavy users abstaining from smoking for one day. More study is necessary on its effectiveness in maintaining tobacco abstinence.

Nicotine Blockade.

Nicotine blockade therapy is based on the rationale that if one blocks the rewarding aspects of nicotine by administering an antagonist (or blocker), the smoker who seeks the pleasant effects nicotine produces will be more likely to stop. To be effective, the drug must be active in the central nervous system (brain and spinal cord). Thus mecamylamine, which acts at both central and peripheral nervous system sites, effectively increases rates of abstinence, whereas hexamethonium and pentolinium, which block peripheral nervous system receptors only, have no effect on abstinence. The problem is that there are no pure nicotine antagonists currently available. Drugs like mecamylamine produce side effects, such as sedation, low blood pressure, and fainting, that probably limit their role to that of an experimental tool, not appropriate for clinical treatment.

Deterrent Therapy.

The rationale for deterrent therapy is that pretreatment with a drug may transform smoking from a rewarding experience to an aversive one if the unpleasant consequences are immediate and strong enough. Disulfiram treatment for alcoholism is an example of this type of treatment. After pretreatment, even a small quantity of alcohol can produce discomfort and acute illness. Silver acetate administration is a potential treatment for smokers. When silver acetate contacts the sulfides in tobacco smoke, the resulting sulfide salts are highly distasteful to most people. Although many over-the-counter deterrent products are available, their effectiveness has not been scientifically validated. Additionally, a severe limitation to this treatment is compliance. It may be difficult to ensure that patients continue to take the medication as needed.

BEHAVIORAL TREATMENTS

Characteristics of tobacco dependence and nicotine addiction suggest that combining nicotine replacement, to reduce the physiological disruptions of withdrawal, with behavioral treatments, to counter the conditioning cues, reinforcers, and social context cues associated with smoking, may be especially useful in helping people to quit. Adding behavioral treatments may increase both the rate of successful outcomes and the adherence to the pharmacological treatment. Behavioral interventions for smokers have been tried for many years. This section will focus on several of the current major approaches, but it is by no means comprehensive.

Social support has produced mixed results. Enlisting the help of the smoker's spouse and coworkers, or encouraging participation in a group, has yielded generally positive outcomes, but attempts to enhance social support further have been uniformly unsuccessful. Providing skills training in coping with stress and negative emotions has also been tried but generally as part of a multicomponent treatment plan. If the person smokes during times of stress and negative emotions, learning other means of dealing with these situations may lessen the need to smoke. Skills training appears beneficial in the short term, especially when combined with aversive smoking procedures (discussed below), but its long-term benefits are less clear. Mixed but generally negative results have been reported, but a problem in assessing skills training is that researchers have not controlled for the differences in treatments available. Some may be more effective than others. The techniques should be available for clients long after learning in order to be beneficial for long-term smoking cessation.

Contingency contracting uses operant conditioning techniques to reinforce quitting or punish smoking behaviors. Procedures include collecting monetary deposits from clients early in treatment and providing periodic repayment as nonsmoking goals are reached, having a client pledge to donate money to a disliked organization for every cigarette smoked, or similar procedures using nonmonetary rewards or punishers. Research indicates that contingency contracting aids quitting at least in the short term. Stimulus control procedures gradually eliminate situations in which the client smokes (e.g., only smoke outside) or the time the client smokes (e.g., only on the half hour) to reduce the number of cues for smoking.

Nicotine fading gradually changes brands or cigarette filters the smoker uses, in order to decrease tar and nicotine per cigarette before complete cessation. It is hoped this strategy will decrease later withdrawal symptoms when the client stops smoking. Problems are that the procedure may do nothing to reduce cravings (considered important for relapse prevention) and that the nicotine reduction is not as large as one would expect from ratings of the cigarettes' contents, because people change the way they smoke to receive more nicotine from each cigarette. Improved outcomes may occur with nicotine fading when it is part of multicomponent treatment approach.

Aversion treatments are designed to condition a distaste for cigarettes by pairing smoking with either unpleasant imagery (covert sensitization), electric shock, or unpleasant effects of smoking itself through directed smoking procedures. Directed smoking techniques include satiation, rapid smoking, and focused smoking. In satiation, clients smoke at least at twice their regular rate. Research indicates a low, 15 percent success rate when satiation is used by itself, versus 50 percent when it is part of a multicomponent program. In rapid smoking, clients inhale every 6 seconds until they will get sick, usually for six to eight sessions. As part of a multicomponent program, good outcomes are seen, but success is variable when rapid smoking is used alone, with high immediate abstinence rates, followed by low long-term rates. In focused smoking, clients either smoke for a sustained period at a slow or normal rate or do rapid puffing without inhaling. Long-term outcomes are similar to or slightly lower than for rapid smoking. The utility of aversion procedures is limited because the aversions are rarely permanent, and it is difficult to condition aversion to a substance that has had repeated past use.

CONCLUSIONS

Multicomponent interventions that combine pharmacological and behavioral components appear to be the best treatment strategies, often producing very high short-term (nearly 100% for the best programs) and impressive long-term success rates (at or above 50%). Ideally, the components should complement one another; however, it is not known how the separate components work in combination. It is possible that, because people smoke for different reasons (to prevent withdrawal, to ease anxiety, to relax, to achieve pleasant effects), a program that includes components that target enough different reasons for smoking will be successful in most cases. Second, it is not known which components work best together or how to target interventions for particular types of people. Third, a concern in designing a multicomponent treatment plan is that too many interventions may decrease patient compliance. Despite these gaps in our knowledge, smoking-cessation programs are improving constantly, and smokers do not have to go it alone in their attempts to quit.

(See also: Addiction: Concepts and Definitions ; Nicotine Delivery Systems for Smoking Cessation ; Relapse Prevention ; Tobacco ; Treatment Types )

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Leslie M. Schuh

Jack E. Henningfield

Revised by Rebecca J. Frey

Tobacco, Psychological Approaches

Persistent use of tobacco products is believed to result from the rewarding effects of nicotine, a psychostimulant found in tobacco. Individuals become dependent on tobacco, in part, because of nicotine's positive psychoactive effects (e.g., mild euphoria, stimulation, improved concentration). Continued use of tobacco products is also reinforced by the alleviation of unpleasant withdrawal symptoms that often occur during nonuse or abstinence (e.g., irritability, weight gain). However, tobacco dependence results not only from the pharmacological effects of nicotine that eventually lead to physical addiction, but also from the psychological and behavioral components associated with tobacco use.

Psychological reliance on tobacco is likely to be a result of the psychoactive effects from nicotine and the use of tobacco. For example, a cigarette smoker may smoke to modulate moods or deal with stress. The behavioral components are a result of learning that certain contexts or stimuli are associated with smoking behavior with consequent desirable effects. After repeated self-administration of nicotine-containing tobacco products, these contexts or stimuli begin to control behavior. Pharmacological treatments are often used to deal with the physical addiction to nicotine. However, psychological or behavioral approaches are used to help smokers learn more adaptive ways to deal with situations other than using tobacco products and to engage in more adaptive behavior in response to stimuli associated with smoking.

This section will discuss assessing whether tobacco users are ready to quit tobacco products, methods to motivate them to quit, and behavioral treatment methods that have been found to be effective, and combining pharmacological and behavioral treatment approaches.

ASSESSMENT OF READINESS TO QUIT TOBACCO USE

The application of behavioral treatments to tobacco-dependent individuals begins with an assessment of preparation for change. Readiness to change negative health behaviors has conceptualized in the transtheoretical model originated by James Prochaska and Carlos DiClemente. This model posits that there are reliable Stages of Change in health awareness and motivation, and that appropriate treatments vary by the stage. There are five stages of change: (1) pre-contemplation, a period where during the next 6 months, the tobacco user is not considering quitting; (2) contemplation, a period when a tobacco user is seriously considering quitting in the next 6 months; (3) preparation, a period when, a tobacco user who tried quitting in the previous year, thinks about quitting in the next month; and (4) action, a 6 month period after the tobacco user makes overt changes to stop using tobacco products. The last stage, maintenance, is the longest and describes the tobacco-free period after cessation. To assess stage of change, informal questioning or a brief list of structured questions (i.e., the University of Rhode Island Assessment Scale [URICA]), has been employed.

At any time, the majority of smokers are precontemplators, contemplators, or preparers, and these individuals lack the motivation to justify the intensive behavioral techniques described below. The behavioral techniques described later in this section are most applicable to the action stage. At all stages of change, education about nicotine dependence is essential. Education about nicotine dependence should emphasize a couple of major points. First, chronic use of nicotine changes the brain, leading to a complex neurobiological disorder. Second, nicotine withdrawal is a difficult but time-limited syndrome typically taking one to three weeks to subside, with weight gain and cravings persisting longer. Nicotine withdrawal can involve negative mood, insomnia, anxiety, impaired attention and concentration, restlessness, and weight gain. Knowing why one uses tobacco and what lies ahead as well as knowing that effective treatment techniques are available, can help to motivate a quit attempt and enhance self-efficacy, the belief that one has the ability and tools to achieve abstinence from tobacco. For those in the action stage, providing counseling that involves problem solving and developing coping skills is most effective.

PRINCIPLES OF BEHAVIORAL MODIFICATION

Classical behavioral treatments in tobacco cessation are based on the principles of behavioral modification, where the antecedents and the consequences of tobacco-use behavior are examined. Consequences are events that occur after the use of tobacco. If the consequences increase behavior, then the process is termed reinforcement. There are two major types of reinforcement: positive and negative. Positive reinforcement involves the presentation of an event that then increases behavior. Negative reinforcement involves the removal of an event that also results in increased behavior.

Both positive and negative reinforcements initiate and maintain tobacco use. Positive reinforcement from smoking cigarettes, for example, may include improving concentration. Negative reinforcement from smoking cigarettes may include reduction of tension, depressed mood, or prevention of withdrawal symptoms.

If the consequence decreases behavior, then the process is termed punishment. Punishment can involve presentation of an event or removal of an event. For example, the occurrence of social disapproval, negative physical consequences, and increased cigarette taxes may reduce smoking. Similarly, the removal of privileges, such as being unable to participate in sports can decrease smoking behavior and serve as punishment.

Despite the many negative consequences of tobacco use, it often persists in many who try it. There are many antecedents or events that precede tobacco use, that begin to control or maximize the occurrence of tobacco use, the process called stimulus control. An individual learns that in certain situations, behavior is reinforced; while in other situations, it is either not reinforced or punished. For example, a smoker may learn smoking in bars is reinforced socially as well as by nicotine's effects, whereas smoking in church is not reinforced. Upon repeated experiences, frequenting bars begins to automatically elicit the desire or behavior for smoking, while in contrast attending church does not. In large part, the punishing effects of tobacco use and particularly the reinforcing effects of cessation are relatively remote (i.e., occur years in the future), while the reinforcing consequences of smoking (e.g., mood regulation) are more immediate. The strength of any reinforcer or punishment diminishes the further removed from the actual behavior, and thus tobacco use is often maintained for decades.

Behavioral treatments involve manipulating these antecedents and consequences to reduce the probability of tobacco use. Further, skills that foster non-tobacco use behaviors such as stress management skills and assertiveness are also taught or encouraged.

BEHAVIORAL, SUPPORTIVE, AND OTHER TREATMENTS

Since the 1960s, many behavioral techniques have been developed to help tobacco dependent people quit, but only a few techniques have shown reliable evidence of efficacy. Efficacy is generally defined by comparing abstinence rates (i.e., proportion not using tobacco products) at six months or a year after quitting. In 2000, the Agency for Health Research and Quality (AHRQ) released a second comprehensive evaluation of these techniques using meta-analysis, a method of quantitative literature review. The review identified four areas of behavioral treatment or psychosocial support that were associated with significantly higher quit rates: (a) intra-treatment support; (b) extra-treatment support; (c) problem solving and skills training; and (d) aversive techniques. The first two approaches represent supportive psychological treatments, whereas the latter two emphasize behavioral aspects of smoking and employ some principles of behavioral modification. Before considering them, the actual act of quitting and relevant approaches are detailed. Finally, brief descriptions of some techniques whose clinical efficacy has not been supported will be provided.

QUITTING

Several techniques have been developed to help the individual quit using tobacco products. One technique, quitting abruptly ("cold turkey"), is best executed on a planned quit day and as part of a broader treatment strategy (e.g., involving intra-treatment support). In contrast, gradual reduction involves slowly reducing tobacco use until it reaches zero. Several reduction approaches are available including one where the number of cigarettes smoked each day is reduced (either through lengthening the time between cigarettes or delaying the onset of smoking) and one where situations where tobacco is used are slowly restricted. Unfortunately, a significant number of smokers experience difficulty in reducing the number of cigarettes beyond a certain point. Other gradual reduction methods include using cigarette filters with ventilation holes that can decrease the amount of nicotine obtained from each cigarette or gradually reducing the nicotine content of the cigarette. However, these methods may result in compensatory smoking, that is puffing more or longer, or smoking more cigarettes to make up for reduced nicotine. An important goal of tobacco reduction methods is the reduction of withdrawal signs and symptoms from tobacco, which gradual reduction does in fact achieve. However, gradual reduction may prolong withdrawal symptoms for a period longer than abrupt cessation.

Since the 1980s, a number of pharmacological agents have been developed for the treatment of smokers. Nicotine replacement therapies (e.g., nicotine gum) and novel non-nicotine pharmacotherapies, such as buproprion (Zyban) have been found to significantly reduce withdrawal signs and symptoms. Because of the uniform efficacy of these products, their use has been recommended for most smokers to aid cessation (excluding smokers who have certain medical illnesses, pregnant women, or adolescents).

In summary, tobacco users are typically advised to set a quit date and to take medications to assist in their cessation efforts. If a smoker does not want to use medications, abrupt cessation can be used or if the smoker is concerned about withdrawal, a gradual approach may be taken.

INTRA-TREATMENT AND EXTRA-TREATMENT SUPPORT

The process of quitting smoking can be difficult, and support and encouragement can greatly help. In intra-treatment support, healthcare providers (e.g., physicians) improve quit-rates through support and encouragement (e.g., by recognizing the discomfort of quitting, underscoring that half of all smokers have quit for good, and noting that effective therapies exist). In addition, by providing training in acquiring extra-treatment support, the tobacco user can effectively obtain additional care from family members, friends, and telephone hotlines. Further, supportive others (e.g., spouse) can be contacted with information on tobacco cessation or encouraged to participate directly in treatment with the tobacco user.

PROBLEM SOLVINGAND SKILLS TRAINING

Problem solving and skills training involve learning to recognize patterns of tobacco use and situations where use is common through self-monitoring and learning ways to effectively deal with these high risk situations.

Self-monitoring requires an individual using tobacco products to monitor situations and feelings that are associated with tobacco use. Through self-monitoring, the individual begins to recognize specific antecedent conditions that are associated with the use of tobacco. Antecedent conditions for a cigarette smoker often involve environmental contexts or situations (e.g., smoking the first thing in the morning) while others involve internal cues or psychological states (e.g., being under pressure). In these situations, tobacco users are most likely to experience craving or an urge to use tobacco products. Understanding and recognizing these situations and psychological states will promote learning skills to handle them.

Adequate problem solving and coping skills are essential to remaining tobacco free. Problem solving includes learning how to assess potential relapse situations adequately, developing a number of solutions, and trying out these solutions. Solutions involve the use of coping skills. One type of coping skill is learning how to deal with stimulus control or high-risk situations. One method is to avoid stimuli associated with tobacco, such as the smoking section of a restaurant. Also, smokers can put themselves in situations that prevent or discourage tobacco use (e.g., movie theatre, non-smoking restaurant). Unavoidable situations and psychological states can be countered through cognitive strategies such as distraction and positive thinking. Other techniques include using substitutes that may simulate some of the stimulus qualities or effects of smoking (e.g., chewing gum, sucking on straws). In addition, craving to use tobacco products lasts only minutes, and using distractions (e.g., exercising) can occupy the tobacco user until the craving passes. Tobacco users are also taught to practice refusing tobacco or asking others not to use tobacco around them. Often tobacco users have employed nicotine instead of coping skills that could be used to counter stress and negative affect, and training in use of adaptive coping skills can be beneficial.

The deprivation of nicotine and tobacco can be offset by the provision of rewards. Rewards can include saving money that is typically spent on cigarettes to reinforce the cost of the habit and to pay for pro-health activities like vacations. Rewards can also be leisure activities (e.g., reading a book, going to a movie). Finally, rewards can be self-affirming statements such as, "I did really well today." Rewards are initially given for small successes, based on achieving a goal behavior (e.g., not smoking for 72 hours), and occur as soon as possible upon completion of this behavior.

AVERSIVE TECHNIQUES

Rapid smoking is one aversive technique that has been found effective. Smokers are asked to smoke several consecutive cigarettes rapidly so that they will experience immediate adverse, punishing effects (e.g., nausea), thereby reducing the desire to smoke. Similarly, reduced-aversion techniques also facilitate smoking cessation by their unpleasant effects and improve the effectiveness of behavioral treatment. This technique involves focusing on smoking while the person smokes for a sustained period of time, or on rapid puffing with no inhalation of the smoke.

OTHER TECHNIQUES

Several other techniques for tobacco cessation have failed to show results superior to a non-treatment control group, but may still be useful in treatment programs that employ multiple behavioral techniques. Relaxation or breathing techniques involve deep breathing or meditation in anticipation or response to urges to use tobacco. Programs designed to specifically counter negative affect seek to help the tobacco user to identify negative feelings, assess and appraise the situations that lead to the negative affect, and respond to them realistically and productively. Programs designed to counter increased weight on cessation (on average about seven pounds), have not improved quit rates, and can actually reduce the chances of successfully quitting. Two commercial treatments, hypnosis and acupuncture continue to be popular, but their lack of efficacy and unclear bases for action do not support their use.

INTENSITY OF BEHAVIORAL TREATMENT

A separate question from which behavioral treatments to give is how much or how intense the treatment should be? Treatment intensity involves the number of treatment sessions, the length of these sessions, and also the total amount of time spent throughout treatment providing behavioral treatments and support. The AHRQ guideline recommends that an intensive treatment should include four or more sessions, with each session lasting at least ten minutes, and that the total contact time should be longer than thirty minutes. Providing additional contact time and support will increase quit rates, but need to be weighed against the financial costs and likely loss of patient participation if the contact is spread of many weeks.

RELAPSE PREVENTION

Once a tobacco user has quit consuming tobacco, the challenge is to prevent relapse, the return to regular tobacco use. Relapse is distinguished from a slip, which is smoking one or few cigarettes after a period of abstinence. However, slips, especially during the initial weeks of quitting, generally lead to relapse. Therefore, smokers or tobacco users are instructed not allow themselves use of any tobacco products (e.g., not one puff). Maintaining abstinence involves developing both behavioral and cognitive skills that go beyond the initial challenges of nicotine withdrawal. Long term abstinence may be supported through health-oriented lifestyle changes such as increased levels of physical activity, proper eating, obtaining enough sleep and rest, and managing or changing levels of stress in adaptive ways.

CONCLUSION

Many of the techniques used in psychological treatment for smoking cessation have been described in this article. Studies show that smoking interventions are most effective when multiple techniques are used, and that increasing treatment contact can further improve treatment outcome. Unfortunately, nicotine is a highly addictive drug, and relapse to smoking cigarettes or other tobacco use remains high, in spite of behavioral treatment and pharmacological interventions. Following treatment, most tobacco users begin to relapse with only twenty to thirty percent still tobacco free after six months from quitting.

Use of both pharmacotherapies and psychological treatments for smoking cessation can increase success rates, with combinations used to target different aspects of nicotine addiction. For example, pharmacotherapies such as nicotine gum or bupropion reduces the physical dependence aspects of smoking, which then allows the tobacco user to focus on the behavioral or psychological aspects of smoking. The intensity of behavioral treatment and whether pharmaceutical treatments are prescribed depends on the characteristics of the smoker (e.g., degree of dependence).

In order to help tobacco users receive treatment appropriate to their stage of change and tobacco and health histories (i.e., level of nicotine dependence, previous quit attempts), a stepped care model has been proposed. In the stepped care framework, a process called tailoring is used so that the most appropriate treatment is given. Those in the precontemplation, contemplation, and action stages are given information about the health risks of tobacco use, the benefits of cessation, resources for a later quit attempt, and a follow-up is planned to reassess their readiness to quit. When tobacco users make an initial quit attempt a minimum of intra-treatment behavioral support is used, in conjunction with self-help materials and if necessary pharmacotherapy is recommended. Tobacco users who have failed to quit with less intensive treatments can then be "stepped up" to a program involving more contact, different behavioral interventions, and pharmacotherapies. In all cases, planned follow-up is essential to determine if additional treatment is needed.

Of final note, most cigarette smokers quit on their own, without treatment, but their quit rates are the lowest of any approach (e.g., compared to behavioral or pharmacological treatments). If smokers do seek treatment, they tend to obtain help from their physician or from health-care providers who often do not have time to provide intensive behavioral treatment. Therefore, availability and use of the behavioral techniques for smoking cessation are being increasingly adapted to these various methods or settings for tobacco cessation (e.g., teaching smokers how to obtain extra-treatment support, such as through telephone counseling). Telephone counseling is a particularly promising source of treatment support that can provide intensive counseling without the need for costly travel and missed work. Recently, awareness that tobacco cessation is not possible for all individuals, at least as the initial goal in treatment, has given rise to studies of tobacco use reduction. The role for psychological treatments in this burgeoning area is not clear but will doubtless be important. In the long run, however, societal pressures (e.g., banning smoking in public places) and economic pressures (e.g., increasing taxes on tobacco products) will likely have the greatest impact in reducing tobacco use and in encouraging cessation.

BIBLIOGRAPHY

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Fiore, M. C., Bailey, W. C., Cohen, S. J, .et al. (2000) Treating tobacco use and dependence. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

Glasgow, R. E., & Orleans, C. T. (1997). Adherence to smoking cessation regimens. Eds. David S. Gochman. Handbook of Health Behavior Research II: Provider Determinants. Plenum Press: New York.

Hall, S. M., Rugg, D., Tunstall, C., et al. (1984). Preventing relapse to cigarette smoking by behavioral skill training. Journal of Consulting & Clinical Psychology, 52, 372-82.

Hatsukami, D. K., &Lando, H. A. (1993). Behavioral treatment for smoking cessation. Health Values, 17, 32-40.

Hatsukami, D. K., &Mooney, M. E. (1999). Pharmacological and behavioral strategies for smoking cessation. Journal of Clinical Psychology in Medical Settings, 6, 11-38.

Hughes, J. R. (1995). Combining behavioral therapy and pharmacotherapy for smoking cessation: an update. NIDA Research Monograph, 150, 92-109.

Hughes, J. R. (2000). Reduced smoking: An introduction and review of the evidence. Addiction, 95 (Suppl.), S3-S7.

Hughes, J. R., Goldstein, M. G., Hurt, R. D., et al. (1999). Recent advances in the pharmacotherapy of smoking [see comments]. Jama, 281 (1), 72-6.

Klesges, R. C., & Shumaker SA. (1992). Understanding the relations between smoking and body weight and their importance to smoking cessation and relapse. Health Psychology, 11 (Suppl.), 1-3.

Lichtenstein, E., Glasgow, R. E., Lando, H. A., et al. (1996). Telephone counseling for smoking cessation: Rationales and meta-analytic review of evidence. Health Education Research, 11, 243-257.

Lichtenstein, E., Glasgow, R. E., & Abrams, D. B. (1986). Social support in smoking cessation: In search of effective interventions. Behavior Therapy, 17, 607-619.

Lichtenstein, E., & Glasgow, R. E. (1992). Smoking cessation: What have we learned over the past decade? Journal of Consulting and Clinical Psychology, 60, 518-527.

McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research, and Practice, 20, 368-375.

Pomerleau, O. F., & Pomerleau, C. S. (1987). Break the smoking habit. A behavioral program for giving up cigarettes. Ann Arbor: Behavioral Medicine Press.

Prochaska, J. O., Di Clemente, C. C., & Norcross, J. C. (1992). In search of how people change. Applications to addictive behaviors. American Psychologist, 47 (9), 1102-14.

Shiffman, S. (1984). Coping with temptations to smoke. Journal of Consulting and Clinical Psychology, 52, 261-267.

Shiffman, S., Read, Laura, R., Maltese, J., et al. (1985). Preventing relapse in ex-smokers. In G. A. Marlatt and J. R. Gordon (Eds.), Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.

U.S. Department of Health and Human Services. (1994). Tobacco and the clinician: Interventions for medical and dental practice. NIH Publications no. 94-3693. Washington, D.C: Author.

U.S. Department of Health and Human Services. (1991). Strategies to control tobacco use in the United States: A blueprint for public health action in the 1990s. NIH Publications no. 92-3316. Washington, D.C: Author.

Joni Jensen

Dorothy Hatsukami

Revised by Marc E. Mooney

Twelve Step Facilitation (TSF)

Twelve Step Facilitation (Nowinski & Baker, 1998; Nowinski, Baker, & Carroll, 1992) is a manual-guided, twelve-step based treatment program that includes a range of interventions that are organized into a "core" or basic program, an "elective" or advanced program, and a brief conjoint program for the substance abuser and a significant other. Interventions in the core program are most appropriate for what could be termed the "early" or initial stage of recovery from alcohol or drug dependence, meaning that stage of change in which an individual takes their initial steps from active substance abuse toward abstinence.

TSF is a highly structured intervention whose sessions follow a prescribed format. Each begins with a review of the patient's recovery week, including any 12-step meetings attended and reactions to them, episodes of drinking or drug use versus sober days, urges to drink or use, reactions to any readings completed, and any journaling that the patient has done. The second part of each TSF session consists of presenting new material, consisting of material drawn from the core, elective, or conjoint program. Each session ends with a wrap-up that includes the assignment of recovery tasks: readings, meetings to be attended, and other pro-recovery behavioral work that the patient agrees to undertake between sessions.

The various TSF interventions, or 'topics' are of two types: Core and Elective. Core sessions include Introduction & Assessment, Acceptance, People, Places, & Routines, Surrender, Getting Active. Elective (advanced) sessions include: Genograms, Enabling, Emotions, Moral Inventories, Relationships. There is also a conjoint program.

Patients need not necessarily be dependent on either alcohol or drugs in order to benefit from a 12-step oriented treatment; rather, they must merely satisfy the basic criterion for becoming member of a 12-step fellowship as set forth by Alcoholics Anonymous, namely, "a desire to stop drinking," or to stop using drugs (Alcoholics Anonymous, 1952). However, 12-step fellowships do advocate abstinence, as opposed to controlled use of alcohol or drugs. Historically, these fellowships were founded and exist to provide support and advice, and to facilitate the personal growth of individuals whose own efforts to control their use of alcohol and/or drugs have failed and whose lives have became "unmanageable" as a consequence of substance abuse (Alcoholics Anonymous, 1976).

EARLY RECOVERY

Based on an assessment of the patient's lifestyle, prior treatment experiences, periods of sobriety, and circumstances surrounding relapse, an individual treatment plan is devised, typically including one or more elective topics plus the core TSF program. Broadly speaking, early recovery can be broken down into two phases: acceptance and surrender. Acceptance refers to the process in which the individual overcomes "denial." Denial refers to the personal belief that one either does not have a substance abuse problem, and/or that one can effectively and reliably control drinking or drug use. Acceptance represents a significant insight: That one has in fact lost the ability to effectively control use of alcohol or drugs. Acceptance is marked by a realization that one's life has become progressively more unmanageable as a consequence of alcohol or drug use, and furthermore that individual willpower alone is an insufficient force for creating sustained sobriety and restoring manageability to one's life. Given this realization, acceptance implies that the only sane alternative to continued chaos and personal failure to admit defeat (or one' s efforts to control use), and to accept the need for abstinence as an alternative to controlled use. This is Step I of Alcoholics Anonymous: "We admitted we were powerless over alcoholthat our lives had become unmanageable" (Alcoholics Anonymous, 1976).

As important as insight is, alone it is not sufficient for recovery, and that is where the concept of surrender comes in. Surrender refers to a willingness to take action, and specifically to embrace the twelve steps as a guide for recovery and spiritual renewal. These are Step 2 and 3: We came to believe that a Power greater than ourselves could restore us to sanity; We made a decision to turn our will and our lives over to the care off God as we understood Him (Alcoholics Anonymous, 1976).

AA and NA are programs of action and lifestyle change, as much as they are programs of insight and spiritual renewal. Surrender follows acceptance and represents the individual's commitment to making whatever changes in lifestyle are necessary in order to sustain recovery. Surrender requires action, including frequent attendance at AA and/or NA meetings, becoming active in meetings, reading Aa/na literature, getting a sponsor, making AA/NA friends, and replacing people, places, and routines that have become associated with substance abuse and therefore represent a threat to recovery, with alternative relationships and habits of living. In TSF the action and commitment that are the hallmarks off surrender are guided to some extent by the facilitator; but they are also heavily influenced by individuals the patient encounters and begins to form relationships with within 12-Stop fellowships. One especially significant relationship that TSF actively advocates for in early recovery is that of the sponsor, who is someone already in recovery and active in a fellowship who offers guidance and support to the newcomer.

SPIRITUALITY

Twelve step fellowships regard spirituality as a force that provides direction and meaning to one's life, and they equate spiritual awakening with a realignment of personal goals, specifically a movement away from radical individualism and the pursuit of the material, toward community and the pursuit of serenity as core values.

The twelfth step of AA states: "Having had a spiritual awakening as the result off these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs" (Alcoholics Anonymous, 1952). AA and its sister 12-Step fellowships have a long spiritual tradition, in that they challenge individuals to believe in a center of power that is greater than personal willpower. This "Higher Power" may be the fellowship itself. Substituting faith in the group (or some other higher power) for faith in personal willpower, is the essence of 12-Step recovery, and it has been likened to a form of spiritual conversion or awakening (Fowler, 1993). 12-Step fellowships believe that those who thoroughly follow their program of recovery will eventually benefit spiritually: That they will re-evaluate themselves in terms of how they relate to others, their personal goals, and their sense of purpose in life.

EFFICACY OF 12-STEP BASED TREATMENT

TSF has been found to be effective in producing significant and sustained reductions in alcohol use (Project Match Research Group, 1997; Seraganian et al., 1998). A further finding from Project Match, and supported by other research (Fiorentine, 1999), is a correlation between attendance at 12-step meetings and abstinence from alcohol and drug use. Finally, greater involvement in 12-step fellowships (e.g., getting a sponsor, taking on responsibilities) has been found to correlate positively with recovery (Emrick, 1993). Taken together, these studies offer empirical support for the efficacy of these widely used models of treatment, particularly when therapists are trained to deliver this manualized approach competently.

BIBLIOGRAPHY

Alcoholics Anonymous (1976). Alcoholics anonymous: The story of how many thousands of men and women have recovered from alcoholism (3rd ed.). New York: Alcoholics Anonymous World Services.

Emrick, C. (1993). Efficacy of Alcoholics Anonymous: A meta-analysis of research. In B. S. McCrady & W. R. Miller (Eds.), Research on Alcoholics Anonymous: Opportunities and alternatives. New Brunswick, NJ: Rutgers Center of Alcohol Studies.

Fiorentine, R. (1999). After drug treatment: Are 12-step programs effective in maintaining abstinence? American Journal of Drug and Alcohol Abuse, 25 (1): 93-116.

Fowler, J. (1993). Alcoholics Anonymous and faith development. In B. S. McCrady & W. R. Miller (Eds.), Research on Alcoholics Anonymous: Opportunities and alternatives. New Brunswick, NJ: Rutgers Center of Alcohol Studies.

Nowinski, J.&Baker, S. (1998). The twelve-step facilitation handbook: A systematic approach to early recovery from alcoholism and addiction. San Francisco: Jossey-Bass.

Nowinski, J., Baker, S., & Carroll, K. (1992). Twelve-step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. DHHS Publication Mo. ADM 92-1893, Project MATCH Monograph Series, Vol. 1. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogeneity; Project MATCH Posttreatment drinking outcomes. Journal of Studies on Alcoholism, 58, 7-29.

Seraganian, P., Brown, T. G., Tremblay, J., et al. (1998). Experimental manipulation of treatment aftercare regimes for the substance abuser. National health research and development program (Canada), Project #66O5-4392-404. Concordia University, Montreal, Canada.

Joseph Nowinski

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GORDIS, ENOCH; FULLER, RICHARD K.; ALLEN, JOHN P.; LITTEN, RAYE Z.; MILLER, WILLIAM R.; DAVIDSON, ANNE; FULLER, RICHARD K.; LITTEN, RAYE Z.; FREY, REBECCA J.; O'BRIEN, CHARLES P.; DACKIS, CHARLES A.; HIGGINS, STEPHEN T.; OHLENROTH, PATRICIA; KOSTEN, THOMAS R.; OHLENROTH, PATRICIA; LESHNER, ALAN I.; STITZER, MAXINE L.; KIDORF, MICHAEL; ROSEN, MARC; FREY, REBECCA J.; ROFFMAN, ROGER A.; STEPHENS, ROBERT S.; MARTIN, GARTH; SWIFT, ROBERT M.; FREY, REBECCA J.; KOZLOWSKI, LYNN T.; OHLENROTH, PATRICIA; SCHUH, LESLIE M.; HENNINGFIELD, JACK E.; FREY, REBECCA J.; JENSEN, JONI; HATSUKAMI, DOROTHY; MOONEY, MARC E.; NOWINSKI, JOSEPH. "Treatment." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2001. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

GORDIS, ENOCH; FULLER, RICHARD K.; ALLEN, JOHN P.; LITTEN, RAYE Z.; MILLER, WILLIAM R.; DAVIDSON, ANNE; FULLER, RICHARD K.; LITTEN, RAYE Z.; FREY, REBECCA J.; O'BRIEN, CHARLES P.; DACKIS, CHARLES A.; HIGGINS, STEPHEN T.; OHLENROTH, PATRICIA; KOSTEN, THOMAS R.; OHLENROTH, PATRICIA; LESHNER, ALAN I.; STITZER, MAXINE L.; KIDORF, MICHAEL; ROSEN, MARC; FREY, REBECCA J.; ROFFMAN, ROGER A.; STEPHENS, ROBERT S.; MARTIN, GARTH; SWIFT, ROBERT M.; FREY, REBECCA J.; KOZLOWSKI, LYNN T.; OHLENROTH, PATRICIA; SCHUH, LESLIE M.; HENNINGFIELD, JACK E.; FREY, REBECCA J.; JENSEN, JONI; HATSUKAMI, DOROTHY; MOONEY, MARC E.; NOWINSKI, JOSEPH. "Treatment." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2001. Encyclopedia.com. (June 30, 2016). http://www.encyclopedia.com/doc/1G2-3403100460.html

GORDIS, ENOCH; FULLER, RICHARD K.; ALLEN, JOHN P.; LITTEN, RAYE Z.; MILLER, WILLIAM R.; DAVIDSON, ANNE; FULLER, RICHARD K.; LITTEN, RAYE Z.; FREY, REBECCA J.; O'BRIEN, CHARLES P.; DACKIS, CHARLES A.; HIGGINS, STEPHEN T.; OHLENROTH, PATRICIA; KOSTEN, THOMAS R.; OHLENROTH, PATRICIA; LESHNER, ALAN I.; STITZER, MAXINE L.; KIDORF, MICHAEL; ROSEN, MARC; FREY, REBECCA J.; ROFFMAN, ROGER A.; STEPHENS, ROBERT S.; MARTIN, GARTH; SWIFT, ROBERT M.; FREY, REBECCA J.; KOZLOWSKI, LYNN T.; OHLENROTH, PATRICIA; SCHUH, LESLIE M.; HENNINGFIELD, JACK E.; FREY, REBECCA J.; JENSEN, JONI; HATSUKAMI, DOROTHY; MOONEY, MARC E.; NOWINSKI, JOSEPH. "Treatment." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2001. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3403100460.html

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