Abstinence attempts

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. 

Fig. 1 Simplified diagram of sex differences in nicotine addiction. Considering both human smoking conditions and nicotine administration in animals, there are consistent sex differences, specifically during transition from use to dependence and during quit attempts, withdrawal, and relapse. Females take a shorter time to become addicted than males, make fewer attempts to abstain, and have shorter abstinent periods. Finally, females relapse more than males, indicating lower success in quitting...

Studies on rodents point to similar sex differences, suggesting the involvement of underlying sexual dimorphisms in biology. Females may take a shorter time to become dependent than males, and they make fewer quit attempts and can stay abstinent for shorter periods than males the rate of relapse is higher in females than males (Donny et al. 2000 Perkins 2001 Pogun 2001). Figure 1 summarizes the sex differences observed in tobacco/nicotine addiction. 

For those patients who are not ready to attempt total abstinence, methadone or LAAM maintenance therapy is warranted. These maintenance treatments should be incorporated into a comprehensive treatment plan. 

Treatment with Zyban should be initiated while the patient is still smoking, because approximately 1 week of treatment is required to achieve steady-state blood levels of bupropion. Treatment with Zyban should be continued for 7 to 12 weeks. If a patient has not made significant progress towards abstinence by the seventh week of therapy with Zyban, it is unlikely that he or she will quit during that attempt, and treatment should probably be discontinued. Dose tapering of Zyban is not required when discontinuing treatment. 

Nicotine and tobacco dependence is best treated as a chronic condition with remission and relapse. Up to 80% of tobacco users say they would like to quit. About one third of smokers try to quit each year, 90% of these without treatment, but only 2.5-5% are successful. Of those who try to quit without treatment, more than 90% fail, with most relapsing within a week. Most people experience relapses and require repeated attempts before achieving long-term abstinence. However, effective treatments do exist, and eventually 50% of smokers succeed in permanently quitting. 

An attempt was made to measure opiate abstinence responses in the guinea pig ileum made dependent in vitro (Cruz et al. 1991). 

Data from 75 participants in a longitudinal study of metamfetamine abusers has attempted to differentiate the cognitive performance of those who remained abstinent, relapsed, or continued to use metamfetamine during treatment (25). Relapse of metamfetamine abuse can affect episodic memory differently than it affects other cognitive functions. This highlights the fact that individuals who are either abstinent or relapsing may have more problems with treatment that requires their attention, understanding, and memory for compliance than those who continue to use metamfetamine. 

Abstinence on its own is not enough for the addict. Addiction is a function of the lower brain and cannot be controlled by force of will. Craving will wear down the addict s resolve and in an attempt to resist can create a rigidity known in the field as white-knuckle sobriety, in which the abstinent addict is clinging so hard that it is like the driver with such a grip on the wheel that his or her knuckles are bloodless. That is no way to drive a car or to maintain recovery from addiction. Recovery for the addict is a lifelong undertaking and requires help. ... 

One major reason for the movement away from the medical use of barbiturates involves tolerance and dependence. Tolerance develops fairly rapidly to many effects of the barbiturates. Whereas a given dose may be effective at inducing sleep for a while, if the drug is used regularly the patient soon may require a higher dose in order to sleep. If doses escalate too much and regular use persists, the patient will experience an abstinence syndrome when he or she attempts to withdraw from barbiturates. The symptoms of the barbiturate withdrawal syndrome are similar to those of alcohol— shakes, perspiration, confusion, and in some cases full-blown delirium tremens (DTs) (see Chapter 9)—but convulsions and seizures are more likely to occur in barbiturate... 

Many people became dependent on barbiturates even though the drugs were used only under medical supervision. Suppose someone is in crisis—say, after the death of a spouse or other loved one. A physician may prescribe a sleeping pill to help the person rest during the crisis. After a tew weeks the patient may feel emotionally ready to sleep without the drug—and indeed may be. But the first night he or she attempts to sleep without the barbiturate, the person may have a great deal of trouble because one of the features of barbiturate withdrawal is rebound insomnia (Mendelson, 1980). That is, after the chronic use of barbiturates, abstinence produces insomnia even in someone who was untroubled with insomnia previously. 

Methadone is used clinically (1) for relief of pain, (2) to treat opioid abstinence syndrome, and (3) to treat heroin addicts in an attempt to wean them from illicit IV drug use. ... 

Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients who are attempting to quit smoking. Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates ... 

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