Abstinence

A common strategy for treating chronic opiate addiction iavolves the substitution of methadone which can either be provided as maintenance therapy or tapered until abstinence is achieved. Naltrexone and buprenorphine [52485-79-7] have also been used ia this manner. The a2 adrenergic agonist clonidine [4205-90-7] provides some rehef from the symptoms of opiate withdrawal, probably the result of its mimicking the inhibitory effect of opiates on the activity of locus coerukus neurons. 

In order to avoid conception, abstinence from sexual intercourse during the fertile period of the menstmal cycle must be practiced (77,104). It has been deterrnined that the fertile period in women occurs before menstmation (105,106), and formulas have been developed to determine the fertile and infertile days of the menstmal cycle. Ovulation has been linked to a cycHc shift in basal body temperature (107), which can be used retrospectively to determine the time of ovulation. 

The primary difficulty with periodic abstinence is the month-to-month variation in the time of ovulation. Whereas the ovum can only be fertilized during the first 12 to 24 hours after its release from the ovary, sperm remain viable longer in the female reproductive tract, able to fertilize an ovum for 5—7 days and perhaps longer. Thus, intercourse several days prior to ovulation can result in pregnancy. 

The abstinence syndrome (synonym, withdrawal symptom) is observed after withdrawal of a dtug to which a person is addicted. For example, the abstinence syndrome after alcohol withdrawal is characterized by tremor, nausea, tachycardia, sweating and sometimes hallucinations. 

Drug addiction is defined as a syndrome in which drug use (e.g., psychostimulants, opiates, alcohol) pervades all life activities of the user. Life becomes governed by the drug and the addicted patient can lose social compatibility (e.g., loss of partner and friends, loss of job, crime). Behavioral characteristics of this syndrome are compulsive drug use, craving, and chronic relapses that can occur even after years of abstinence. 

Chronic administration of opiates and alcohol leads to physical dependence a phenomenon, which is only weakly expressed following chronic administration of psychostimulants or other drugs of abuse. Physical dependence results from neuroadaptive intracellular changes to an altered pharmacological state. Abstinence from chronic opiate or alcohol use leads to a variety of physiological and psychological withdrawal symptoms based on these adaptations of the neuronal system. 

Lichtenberg- Kraag B, May T, Schmidt LG et al (1995) Changes of G-protein levels in platelet membranes from alcoholics during short-term and long-term abstinence. Alcohol Alcohol 30 455-464... 

When a patient does not have a painful terminal illness, drug dependence must be avoided. Signs of drug dependence include occurrence of withdrawal symptoms (acute abstinence syndrome) when tiie narcotic is discontinued, requests for tiie narcotic at frequent intervals around tiie clock, personality changes if the narcotic is not given immediately, and constant complaints of pain and failure of tiie narcotic to relieve pain. Although these behaviors can have other causes, the nurse should consider drug dependence and discuss the problem with tiie primary health care provider. Specific symptoms of tiie abstinence syndrome are listed in Display 19-3. 

Ethanol also reduces the activity of the noradrenergic system in the locus coeruleus, and alterations in norepinephrine activity may account for some aspects of intoxication and the abstinence syndrome. The 0.2 antagonist clon-idine and the P-receptor antagonist propranolol reduce some symptoms of alcohol withdrawal (Bailly et al. 1992 Carlsson and Fasth 1976 Dobrydnjov et al. 2004 Kahkonen 2003 Petty et al. 1997 Wong et al. 2003). 

The pharmacodynamic effects of ethanol are complex, and any attempt to link its actions to specific neurotransmitters or isolated brain regions is simplistic. A complicated neural network involved in the actions of ethanol accounts for its reinforcing, intoxicating, and abstinence effects. At the present time, use of medications that target neurotransmitters and neuromodulators affected by ethanol represents a reasonable strategy for the development of pharmacotherapies that reduce the reinforcing effects of alcohol and the craving and withdrawal symptoms that commonly occur in the context of alcohol dependence. 

In deciding whether disulfiram should be used in alcoholism rehabilitation, patients should be made aware of the hazards of the medication, including the need to avoid over-the-counter preparations that include alcohol, the need to avoid drugs that can interact with disulfiram, and the potential for a DER to be precipitated by alcohol used in food preparation. The administration of disulfiram to anyone who does not agree to use it, who does not seek to be abstinent from alcohol, or who has any psychological or medical contraindications is not recommended. 

Kranzler and Van Kirk (2001) included 11 acamprosate studies in a metaanalysis involving more than 3,000 subjects. The magnitude of the advantage shown by acamprosate over placebo in those studies varied as a function of the outcomes examined, which included the percentage of patients who were abstinent throughout the study, cumulative abstinent days, and the rate of study retention, all of which favored the active medication. Acamprosate yielded outcomes that were, on average, 7%—13% better than those shown by individuals who received placebo. 

A recent meta-analysis of total abstinence as an outcome in clinical trials of acamprosate (Mann et al. 2004) included 17 studies and a total of more than 4,000 patients. The authors found a significant advantage for acampro-... 

Chick et al. (2003) conducted a meta-analysis that included data from 15 studies of acamprosate in an effort to determine whether acamprosate reduces the severity of relapse for patients in abstinence-oriented treatment who fail to abstain completely. Among patients who relapsed to drinking, acamprosate was significantly associated with less quantity and frequency of drinking, compared with placebo, at each of four follow-up periods (i.e., at 30, 90, 180, and 360 treatment days). During each of these periods, there were also fewer acamprosate-treated patients who drank an average of five or more drinks per day. 

In summary, studies involving more than 4,000 patients provided consistent evidence of a beneficial effect of acamprosate in relapse prevention. On the basis of the drug s efficacy (as demonstrated by at least a doubling of the total abstinence rate in three European studies, two of which were of 12 months duration) and a good safety profile, the FDA approved the medica-... 

In summary, despite evidence that most instances of postwithdrawal depression spontaneously remit within a few days to several weeks of abstinence from alcohol (Brown and Schuckit 1988 Schuckit 1983), persistent depression requires treatment. SRIs have become the first-line treatment for depression... 

Amit Z, Brown Z, Sutherland A, et al Reduction in alcohol intake in humans as a function of treatment with zimelidine implications for rrearment, in Research Advances in New Psychopharmacological Treatments for Alcoholism. Edired by Naranjo CA, Sellers EM. Amsrerdam, Elsevier, 1985 Angelone SM, Bellini L, Di Bella D, er al Effects of fluvoxamine and citalopram in maintaining abstinence in a sample of Italian detoxified alcoholics. Alcohol Alcohol 33 151-156, 1998... 

Brown SA, Schuckit MA Changes in depression among abstinent alcoholics. J Smd Alcohol 49 412 17, 1988... 

Chick J, Lehert P, Landron F, et al Does acamprosate improve reduction of drinking as well as aiding abstinence J Psychopharmacol 17 397-A02, 2003 Chrostek L, Jelski W, Szmitkowski M, et al Gender-related differences in hepatic activity of alcohol dehydrogenase isoenzymes and aldehyde dehydrogenase in humans. J Clin Lab Anal 17 93-96, 2003... 

Mann K, Lehert P, Morgan MY The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals results of a meta-analysis. Alcohol... 

Petrakis IL, Trevisan L, Boutros NN, et al Effect of tryptophan depletion on alcohol cue-induced craving in abstinent alcoholic patients. Alcohol Clin Exp Res 23 1151-1155, 2001... 

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