Pharmacotherapy

As discussed previously, there are no replacement pharmacotherapies for alcoholism or cocaine addiction, but antidepressant, antianxiety, and other medication for accompanying psychiatric conditions are useful in the context of a comprehensive treatment program for addictive disorders involving alcohol and cocaine. A major advance in the treatment of alcoholism is the demonstrated efficacy of the opiate antagonist, naltrexone (ReVia™) in prolonging abstinence in alcoholism treatment. Naltrexone blocks opioid receptors in the brain reward system. When naltrexone was used in conjunction with behavioral therapy over a 3-month period, patients receiving the drug after discharge from inpatient treatment were half as likely to relapse compared to those receiving a placebo. Patients receiving naltrexone generally reported fewer drinking days, fewer drinks per session, and lowered craving scores (O'Malley et al., 1996). Naltrexone was approved by the Food and Drug Administration (FDA) for use in treating alcoholism in 1994, but it has not received enthusiastic support from many self-help groups, such as AA, many of whom believe that recovery from alcoholism is best accomplished by abstinence from all drugs.

In Europe two other drugs have been introduced for the treatment of alcohol addiction: acamprosate and gamma-hydroxybutyric acid. Studies have shown results with these medications similar to those seen with naltrexone (Gallimberti et al., 1992; Nalpas et al., 1990; Paille et al., 1995). For example, one randomized controlled trial found acamprosate resulted in higher early abstinence rates (67 percent at 60 days) compared to placebo (50 percent), longer abstinence duration (62 percent acamprosate, vs. 45 percent placebo), and lower drop-out rates (41 percent acamprosate, versus 60 percent placebo) (Sass et al., 1996). Both acamprosate and gamma-hydroxybutyric acid may mimic the actions of the neurotransmitter, gamma aminobutyric acid (GABA) in the brain, and additional clinical studies are underway in an effort to gain FDA approval for their use in the United States.

Disulfiram (Antabuse®) has been used for many years for the treatment of alcoholism. It causes nausea, vomiting, and other painful and potentially life-threatening side effects if alcohol is consumed, and must be taken daily, so its effectiveness depends on the patient's consistent compliance. Anton (1995) concluded that Disulfiram is effective when its use is closely monitored or where patients are highly motivated or very compliant. In recent years, innovative advanced behavior therapies have been used to sustain compliance.

Effective pharmacotherapy for cocaine addiction remains elusive and is a priority research issue, especially for the National Institute on Drug Abuse's (NIDA's) Medication Development Program (IOM, 1995a). Although pharmacotherapy for underlying psychiatric illness, such as the use of antidepressants to treat depression, seems to augment other therapeutic approaches in cocaine



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