Treatment of Nicotine Dependence

There are an increasing number of options available for the treatment of nicotine dependence. As noted above, nicotine dependence is a chronic, relapsing disorder, and treatment should be approached from this perspective. The U. S. Public Health Service’s Clinical Practice Guideline on Treating Tobacco Use and Dependence is a comprehensive review of smoking cessation research, with recommendations based on numerous meta-analyses. It is the best resource for evaluating currently available treatments, and therefore it is the basis for most of the conclusions that we present here. Pharmacotherapies To date, there are seven FDA-approved medications that reliably increase long-term abstinence rates. These includefive nicotine replacement therapies (NRT) (gum, transdermal patch, inhaler, nasal spray, and lozenge), and two non- nicotine medications (bupropion SR, and varenicline). NRTs are designed to wean smokers gradually off nicotine in a manner that reduces the severity of withdrawal symptoms and cravings to smoke. They are typically used during the first 8–12 weeks of tobacco abstinence. Although the products vary in their routes of nicotine delivery (with the patch providing the most consistent delivery and stable Read more […]

Human Dependence on Tobacco and Opioids: Common Factors

Recent years have seen increasing acceptance of the notion that tobacco is an addictive or dependence-producing substance, particularly as it is used in cigarette smoking. This idea is supported by the observations that tobacco serves as a reinforcer (i.e., it maintains behavior leading to its use) and that most people who smoke cigarettes would like to quit but cannot, even in the face of well documented health risks and economic sacrifices (Surgeon General’s Report 1979). The term “drug dependence” suggests that (1) the drug serves as a reinforcer, (2) behavior occurs which is maintained by the opportunity to take the drug, and/or (3) other reinforcers are sacrificed as a consequence of taking the drug (). Many cigarette smokers in some degree satisfy these criteria for drug dependence (). Since cigarette smoking has only recently been conceptualized as an instance of drug dependence, it should be useful to systematically compare cigarette smoking with another more thoroughly studied dependence process such as opioid dependence or narcotic addiction. At first blush, cigarette smoke and opioid drugs appear to produce vastly differing pharmacological and behavioral effects: large doses of opioids can produce Read more […]

Human Dependence on Tobacco and Opioids: Physiologic Dependence

Physiologic dependence is a factor of significance in opioid dependence and of suspected significance in cigarette smoking. There are three primary aspects of physiologic dependence. The first is important in the maintenance of opioid-taking behavior, in which the emergence of the withdrawal syndrome is correlated with increasingly intense craving scores (). Some analogous findings in animal studies are that the onset of the opioid withdrawal syndrome is correlated with increased rates of drug-taking behavior () and increases in the reinforcing efficacy of opioid drugs (). The second aspect of physiologic dependence to opioids is the increasing propensity of a person in withdrawal to become anxious and to emit aggressive and antisocial acts (). The third aspect of physiologic dependence is the phenomenon of protracted abstinence (), which, in the most rigorous use of the term, refers to physiologic withdrawal signs that are present for more than six months following the onset of opioid abstinence (). Protracted abstinence to opioids has also been well documented in animal studies (). With regard to cigarette smoking, it has been recently postulated that withdrawal phenomena occur and are similar in certain respects Read more […]

Cocaine Abuse: A Review of Current and Experimental Treatments

Cocaine abuse is a recently revived drug problem that is again generating great popular concern. Unfortunately, scientific evaluation of cocaine abuse treatment has been surprisingly sparse kind no consensus exists regarding optimal treatment strategies. This review summarizes current treatment issues and regimens. as well as preliminary data on new, approaches to cocaine abuse treatment. Since this chapter will deal with treatment of the cocaine abuser, it is important from the outset to define what is meant by that term. Although in some settings any use of illegal drugs equals abuse such a definition is more legal than medical and will not he used here. Instead the definition of drug abuse found elsewhere in the field will be employed namely…“the nonprescription use of psychoactive chemicals by an individual to alter his her psychological state in a situation in which the individual or society incurs some harm” (). The great majority of cocaine users applying for treatment fit into this definition. The most common exception is the individual who defines his use as recreational controlled and nonharmful but is brought to treatment by another (e.g. spouse, parent), while the significant other views the cocaine Read more […]

Opioid Use by Adolescents

Screening for alcohol abuse and illicit drug use needs to be a standard procedure in any practice that cares for adolescents and young adults. Recent national surveys indicate that prescription pain relievers have replaced marijuana as the most common entry drugs for adolescents beginning to experiment with drugs. In this chapter, we review appropriate screening tools and management approaches for use in this population. We cover standard treatment options with a focus on the treatment of adolescents dependent on heroin or opioid pharmaceuticals and the promising role of buprenorphine in the treatment of this high-risk population. A case is presented at the end of this chapter, including related questions for additional consideration. Epidemiology Opioid abuse among adolescents is a growing problem in the United States. According to data from the National Institute on Drug Abuse’s Monitoring the Future study, use of “narcotics other than heroin” has doubled among high school students since the year 2000, with marked increases in the use of long-acting oxycodone tablets and hydrocodone-acetaminophen combination tablets. In 2007, the annual prevalence for oxycodone and hydrocodone use reached its highest level Read more […]

Consequences of Prenatal Drug Exposure: Opiates

Epidemiology of Opiate Use in Pregnancy The literature regarding developmental outcomes for infants prenatally exposed to opiates is relatively sparse and was primarily generated in the 1970s and early 1980s. The literature is also made more problematic by the issue of polysubstance abuse, as research investigating prenatal opiate exposure includes exposure to heroin, methadone, or both, and may also include exposure to amphetamines, barbiturates, benzodiazepines, cocaine, alcohol, and nicotine. Recent studies report prevalence for opiate use during pregnancy to range from less than 1 to 2 percent to as high as 21 percent. Growth/Physiological Effects The most consistently reported effect of prenatal opiate exposure is associated with fetal growth retardation and neonatal abstinence syndrome. Neonatal abstinence is described by Kaltenbach and Finnegan () as a generalized disorder characterized by signs and symptoms of central nervous system hyperirritability, gastrointestinal dysfunction, respiratory distress, and vague autonomic symptoms that include yawning, sneezing, mottling, and fever. These early neurobehavioral outcomes do not persist, however. Within the past decade, methadone maintenance has become accepted Read more […]

Maternal Substance Use and Developmental Impact: Tobacco

Epidemiology of Tobacco Use in Pregnancy According to the latest estimates, approximately 27 to 33 percent of women of childbearing age are smokers. Although increasing pressure is being placed on those who smoke to cease during pregnancy, the majority of expecting mothers fail to do so. The Centers for Disease Control (CDC) reports that 20 to 25 percent of expectant mothers continue their tobacco use during gestation. In the National Health Interview Survey, only 27 percent of women were able to immediately quit use when told that they were pregnant and an additional 12 percent were able to quit by the third trimester of pregnancy. Growth Effects Tobacco use by pregnant women raises concerns about potential teratogenic effects. Nicotine and its by-product, cotinine, are found in fetal serum and amniotic fluid at 15 percent higher concentrations than in maternal blood and last for 15 to 20 hours. Large amounts of nicotine and cotinine can be ingested by nursing infants of women who smoke. It has been well documented for many years that tobacco exposure affects fetal growth even after controlling for pertinent demographic and confounding variables. The earliest reported study on human infants who were prenatally exposed Read more […]

Methamphetamine and the Courts: Treatment as a Sentencing Consideration

Although substance abuse in general and methamphetamine abuse in particular have given rise to sentencing enhancement rather than leading to a primary focus on recidivism prevention, the importance of intervention has not been lost in the criminal justice system. Toward that end, as was seen in the review of court cases above, recommendations for treatment as part of probation or conditional release are not uncommon. However, reaching a goal of reducing addictive behavior and the crime that is associated with it depends on having adequate treatment modalities. Treatment for chemical dependency in general and specifically for methamphetamine has not been uniform around the country. There have been a number of attempts through the National Institute on Drug Abuse (NIDA) and American Society for Addiction Medicine (ASAM) to develop standardized treatment protocols that would act as guidelines to programs that treat addiction. However, the penetration of these algorithms in the provider community has been at best sporadic and fragmented. Many providers continue to use a traditional approach to treatment that is primarily based on the disease concept and follows the Hazleton model. This approach, although effective for Read more […]

Consequences of Marijuana Use: Cognitive Effects

Marijuana has long been thought to affect cognitive function. Early reviews, however, concluded that the scientific evidence for long-term deficits was inconclusive. This conclusion remains appropriate if one is referring to gross deficits with severe impairment of functioning. More recent findings from well-controlled studies indicate that cannabis use can lead to subtle, selective cognitive impairment, although the functional significance of these deficits remains unclear. Specifically, tasks requiring “higher cognitive function” show significant deficits associated with chronic and frequent use of cannabis. The ability to organize and integrate complex information appears compromised, most likely due to an impact of cannabis on memory and attentional processes. A considerable research literature in this area has accumulated. Here, we provide a summary of the types of deficits associated with marijuana use in more recent studies and comment on the possible mechanisms involved. Psychomotor Performance Psychomotor performance measures provide a means of evaluating basic cognitive functions such as response slowing. We begin with a summary of this literature because general deficits in this area can affect performance Read more […]

Substance-Related Disorders

The ability to recognize and treat substance use disorders (SUDs) is a core competence in psychosomatic medicine. SUDs are common in both inpatient and outpatient medical settings. Alcohol and tobacco use alone contribute to a host of medical illnesses. Illegal drug use taxes the health care system. Drug and alcohol dependence disorders are best characterized as chronic medical illnesses. Hepatitis C is an example of a potential long-term complication of even brief drug use, injection drug users being at increased risk. Emergency departments have seen a steady increase in overdoses of drugs, including “club drugs” not prevalent until recently. The long-term effects of perinatal drug abuse are becoming known. Devastating complications result from the internal concealment of illicit drugs (e.g., body packing). Core competence in addiction medicine includes the ability to make accurate diagnoses, initiate treatment, and plan and coordinate services. Some hospitals have specialized addiction consultation services, but there is a shortage of board-certified addiction psychiatry specialists. All psychiatrists working in general medical settings are on the front lines of substance abuse and must be sufficiendy knowledgeable. The Read more […]