Alcoholism pharmacotherapy

Longo LP. Progress and issues in alcoholism pharmacotherapy. Primary Psychiatry 1999 6(8) 65-73. 

Lingford-Hughes et al. (2004), Litten and Allen (1999), McLellan, Lewis, O Brien, and Kleber (2000), and O Brien (1996) summarized the major pharmacotherapies available for the treatment of drug-use disorders other than alcohol. Pharmacotherapies have received the most evaluative activity in the treatment of opioid dependence, cocaine dependence, and nicotine dependence. We discussed nicotine replacement therapies in Chapter 7 and therefore do not review them again here. A list of the pharmacotherapies that O Brien (1996) reviewed is presented in Table 15.5. 

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. 

As evidence accumulates showing that a number of medications are efficacious for the treatment of co-occurring psychopathology and/or the prevention of relapse in alcoholic patients, the therapeutic options available to physicians in treating these patients will increase. As these developments unfold, it is crucial that efforts be directed to enhancing the acceptability of pharmacotherapy to the alcoholism treatment community as a standard ingredient in alcoholism rehabilitation. 

Ciraulo DA, Jaffe JH Tricyclic antidepressants in the treatment of depression associated with alcoholism. Clin Psychopharmacol 1 146—150, 1981 Ciraulo DA, Nace E Benzodiazepine treatment of anxiety or insomnia in substance abuse patients. Am J Addict 9 276—284, 2000 Ciraulo DA, Barnhill JG, Jaffe JH, et al Intravenous pharmacokinetics of 2-hydroxy-imipramine in alcoholics and normal controls. J StudAlcohol 51 366-372, 1990 Ciraulo DA, Knapp CM, LoCastro J, et al A benzodiazepine mood effect scale reliability and validity determined for alcohol-dependent subjects and adults with a parental history of alcoholism. Am J Drug Alcohol Abuse 27 339—347, 2001 Collins MA Tetrahydropapaveroline in Parkinson s disease and alcoholism a look back in honor of Merton Sandler. Neurotoxicology 25 117-120, 2004 COMBINE Study Research Group Testing combined pharmacotherapies and behavioral interventions in alcohol dependence rationale and methods. Alcohol Clin Exp Res 27 1107-1122, 2003a... 

Dundon W, Lynch KG, Pettinati HM, et al Treatment outcomes in type A and B alcohol dependence 6 months after serotonergic pharmacotherapy. Alcohol Clin Exp Res 28 1065-1073, 2004... 

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In research and clinical treatment of substance use disorders, pharmacotherapy and psychotherapy are frequently combined. Medication is often used as a maintenance drug, to reduce cravings or intoxication, or to produce aversion to a substance, while the focus of psychotherapy may be to encourage abstinence, teach the patient new coping skills, or improve motivation to address drug or alcohol problems. 

Brief interventions have been applied in pharmacotherapy trials with alcohol-dependent individuals as well (Bohn et al. 1994 Kranzler et al. 1997 Kranz-ler et al. 2003 Naranjo et al. 1995 O Connor et al. 1997). In an open-label... 

Studies have shown that CM can be used to directly reinforce adherence to medication treatments as well (Petty 2000). Liebson et al (1978) found that methadone-maintained alcohol-dependent patients reduced alcohol use when methadone treatment was contingent on disulfiram consumption. To date, one of the most common applications of CM techniques to pharmacotherapy has been the provision of vouchers or cash contingent upon naltrexone consumption in recently detoxified opioid-dependent patients (Carroll et al. 2001, 2002 Preston et al. 1999). These studies have generally reported significant increases in retention and reductions in opioid use among patients receiving the CM treatment, relative to other therapies. 

Many studies have examined the efficacy of a variety of psychosocial treatments for alcohol, cocaine, and opioid use disorders, alone and in conjunction with pharmacotherapy. However, only a handful of studies have explored how these two treatment approaches may interact. More research is needed to further explore the ways in which psychosocial interventions may be used in conjunction with pharmacotherapy to optimize outcomes for both treatments. Providing encouragement for abstinence, greater treatment retention, medication adherence, and coping with medication side effects are some potential applications of psychosocial therapies. 

In some pharmacotherapy studies, psychotherapy exposure has been minimized, on the basis of concern that psychotherapy may produce a ceiling effect on improvement in drug or alcohol use, making medication effects difficult to detect. However, a recent meta-analysis revealed that psychosocial interventions, in fact, may enhance pharmacotherapeutic effects (Hopkins et al. 2002). In this review we have also noted instances where psychosocial and medication treatments have had beneficial additive effects. Minimization of psychotherapy in pharmacotherapy trials may be counterproductive, because psychosocial therapies that encourage the patient to remain engaged in treatment may positively affect patients adherence to the medication regimen, a factor that has an effect on alcohol treatment outcomes (Chick et al. 2000 Volpicelli et al. 1997). 

COMBINE Smdy Research Group Testing combined pharmacotherapies and behavioral interventions in alcohol dependence rationale and methods. Alcohol Clin Exp Res 27 1107-1122, 2003a... 

The final class of pharmacotherapy drugs alters the metabolism of certain target drugs, thereby causing a build up of toxic metabolic products that make a person feel extremely ill. The best known of these metabolism-modifiers is Antabuse (disulfiram), a drug primarily used to discourage people from drinking alcohol. 

The development of pharmacotherapy medications for legal drugs like alcohol and nicotine. Is driven primarily by profit motives. In 2001, Pharmacia (which was acquired by Pfizer In 2003), advised Investors that NIcorette currently controls about half of the worldwide smoking cessation market with sales In 2001 of 299 million, (Pharmacia Corporation 2001 Annual Report, http //media.corporate-ir.net/media fiies/NYS/PHA/reports/ ar2001.pdf), A study completed In 1998, valued the smoking cessation market" at 450 million, and predicted It would reach nearly 1,5 billion by 2007, ( The Market for Smoking Cessation Therapies Will More Than Triple Over the Next Ten Years, (1998, June 10), Press Release, Decision Resources, http //www.forces.org/articies/fiies/pharma.htm)... 

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