Minding the brain: the role of pharmacotherapy in substance-use disorder treatment.

With its medicalization as a brain-based disease, addiction has come to be regarded as amenable to biomedical treatment approaches, most commonly pharmacotherapy. Various vulnerabilities are recognized to contribute to maladaptive substance use, and have been linked to diverse neurobiological alterations that may be targeted with pharmacotherapy: withdrawal, craving and cue reactivity, and aberrant reward processing are the most significant. Here, we summarize current thinking regarding pharmacotherapy for substance-use disorders, grouping medications by the type of vulnerability they propose to address and providing insight into their neurobiological mechanisms. We also examine the limitations of the brain-based disease model in addiction treatment, especially as these shortcomings pertain to the place of pharmacotherapy in recovery. We conclude by sketching a framework whereby medications might be integrated fruitfully with other interventions, such as behavioral, existential, or peer-based treatments, targeting aspects of addiction beyond neurobiological deficits.

La medicalización de la adicción como una enfermedad de base cerebral, ha llegado a ser considerada como una condición sensible a un abordaje terapéutico biomédico, en especial con farmacoterapia. Se han reconocido diversas vulnerabilidades que contribuyen a la mala adaptación al uso de sustancias, las cuales se han vinculado con diversas alteraciones neurobiológicas y con blancos farmacológicos; las más importantes son la abstinencia, el craving y la reactividad a señales, junto con el procesamiento aberrante de la recompensa. En este artículo se resume el pensamiento actual relacionado con la farmacoterapia para los trastornos por uso de sustancias, se agrupan los medicamentos de acuerdo con el tipo de vulnerabilidad a la que ellos están dirigidos y se proporciona una visión acerca de sus mecanismos neurobiológicos. También se examinan las limitaciones del modelo de enfermedad cerebral en el tratamiento de las adicciones, especialmente porque estas alteraciones se relacionan con el papel que tiene la farmacoterapia en la recuperación. Para concluir se propone un esquema en que los medicamentos se pueden integrar de manera fructífera con otras intervenciones como los tratamientos conductuales, existenciales o basados en pares, focalizando aspectos de la adicción más allá de las alteraciones neurobiológicas.

Médicalisée comme une maladie cérébrale, l'addiction est maintenant considérée comme étant susceptible de répondre à des traitements biomédicaux, le plus souvent de la pharmacothérapie. Des vulnérabilités diverses, responsables de l'utilisation inadaptée de substances, sont liées à différentes altérations neurobiologiques et représentent des cibles pharmacologiques dont les plus significatives sont le sevrage, l'état de manque, la réactivité aux indices environnementaux et un fonctionnement anormal du circuit de la récompense. Nous résumons ici les concepts actuels sur la pharmacothérapie des troubles liés à l'utilisation de substances en regroupant les médicaments par type de vulnérabilité traitée et en donnant un aperçu de leurs mécanismes neurobiologiques. Nous analysons aussi les limites du modèle de maladie cérébrale dans le traitement des addictions, surtout lorsque ces failles concernent la place de la pharmacothérapie dans la guérison. Nous concluons en esquissant un cadre selon lequel les médicaments pourraient trouver leur place avec succès aux côtés d'autres traitements comme les traitements comportementaux, existentiels ou collégiaux et qui ciblent des aspects de l'addiction au-delà des déficits neurobiologiques.

Older, Less Regulated Medical Marijuana Programs Have Much Greater Enrollment Rates Than Newer 'Medicalized' Programs.

Twenty-three states and the District of Columbia have passed laws implementing medical marijuana programs. The nineteen programs that were in operation as of October 2014 collectively had over one million participants. All states (including D.C.) with medical marijuana laws require physicians directly or indirectly to authorize the use of marijuana at their discretion, yet little is known about how medical marijuana programs vary regarding adherence to basic principles of medical practice and associated rates of enrollment. To explore this, we analyzed marijuana programs according to seven components of traditional medical care and pharmaceutical regulation. We then examined enrollment rates, while controlling for potentially confounding state characteristics. We found that fourteen of the twenty-four programs were nonmedical and collectively enrolled 99.4 percent of participants nationwide, with enrollment rates twenty times greater than programs deemed to be "medicalized." Policy makers implementing or amending medical marijuana programs should consider the powerful relationship between less regulation and greater enrollment. Researchers should consider variations across programs when assessing programs' population-level effects.

Behavioral naltrexone therapy: an integrated treatment for opiate dependence.

Treatment of opiate dependence with naltrexone has been limited by poor compliance. Behavioral Naltrexone Therapy (BNT) was developed to promote adherence to naltrexone and lifestyle changes supportive of abstinence, by incorporating components from empirically validated treatments, including Network Therapy with a significant other to monitor medication compliance, the Community Reinforcement Approach, and voucher incentives. An overview is presented of the BNT treatment manual. In an uncontrolled Stage I trial (N = 47), 19% completed the 6-month course of treatment. Retention was especially poor in the subsample of patients who were using methadone at baseline (N = 18; 39% completed 1 month, none completed 6 months), and more encouraging among heroin-dependent patients (N = 29; 65% completed 1 month, 31% completed 6 months). Thus, attrition continues to be a serious problem for naltrexone maintenance, although further efforts to develop interventions such as BNT are warranted.

Acupuncture for the treatment of cocaine addiction: a randomized controlled trial.

CONTEXT: Auricular acupuncture is widely used to treat cocaine addiction in the United States and Europe. However, evidence from controlled studies regarding this treatment's effectiveness has been inconsistent. OBJECTIVE: To investigate the effectiveness of auricular acupuncture as a treatment for cocaine addiction. DESIGN: Randomized, controlled, single-blind clinical trial conducted from November 1996 to April 1999. SETTING: Six community-based clinics in the United States: 3 hospital-affiliated clinics and 3 methadone maintenance programs. PATIENTS: Six hundred twenty cocaine-dependent adult patients (mean age, 38.8 years; 69.2% men); 412 used cocaine only and 208 used both opiates and cocaine and were receiving methadone maintenance. INTERVENTION: Patients were randomly assigned to receive auricular acupuncture (n = 222), a needle-insertion control condition (n = 203), or a relaxation control condition (n = 195). Treatments were offered 5 times weekly for 8 weeks. Concurrent drug counseling was also offered to patients in all conditions. MAIN OUTCOME MEASURES: Cocaine use during treatment and at the 3- and 6-month postrandomization follow-up based on urine toxicology screens; retention in treatment. RESULTS: Intent-to-treat analysis of urine samples showed a significant overall reduction in cocaine use (odds ratio, 1.40; 95% confidence interval, 1.11-1.74; P =.002) but no differences by treatment condition (P =.90 for acupuncture vs both control conditions). There were also no differences between the conditions in treatment retention (44%-46% for the full 8 weeks). Counseling sessions in all 3 conditions were poorly attended. CONCLUSIONS: Within the clinical context of this study, acupuncture was not more effective than a needle insertion or relaxation control in reducing cocaine use. Our study does not support the use of acupuncture as a stand-alone treatment for cocaine addiction or in contexts in which patients receive only minimal concurrent psychosocial treatment. Research will be needed to examine acupuncture's contribution to addiction treatment when provided in an ancillary role.