Relapse prevention

Treatment of drug addicts can be sqDarated into two phases detoxification and relapse prevention. Detoxification programs and treatment of physical withdrawal symptoms, respectively, is clinically routine for most drugs of abuse. However, pharmacological intervention programs for relapse prevention are still not veiy efficient. 

Substitution therapy with methadone or buprenorphine has been veiy successfiil in terms of harm reduction. Some opiate addicts might also benefit from naltrexone treatment. One idea is that patients should undergo rapid opiate detoxification with naltrexone under anaesthesia, which then allows fiuther naltrexone treatment to reduce the likelihood of relapse. However, the mode of action of rapid opiate detoxification is obscure. Moreover, it can be a dangerous procedure and some studies now indicate that this procedure can induce even more severe and long-lasting withdrawal symptoms as well as no improvement in relapse rates than a regular detoxification and psychosocial relapse prevention program. 

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-... 

The treatment of co-occurring psychiatric symptoms among alcoholic patients, which can be beneficial in relapse prevention, is an area in which considerable clinical and research interest already exists (Kranzler and Tinsley... 

Brady KT, Myrick H, Henderson S, et al The use of divalproex in alcohol relapse prevention a pilot study. Drug Alcohol Depend 67 323-330, 2002... 

Kranzler HR, Del Boca F, Korner P, et ah Adverse effects limit the usefulness of flu-voxamine for the treatment of alcoholism.] Subst Abuse Treat 10 283-287, 1993 Kranzler HR, Burleson JA, Del Boca FK, et ah Buspirone treatment of anxious alcoholics a placebo-controlled trial. Arch Gen Psychiatry 31 720—731, 1994 Kranzler HR, Burleson JA, Korner P, et ah Placebo-controlled trial of fluoxetine as an adjunct to relapse prevention in alcoholics. Am] Psychiatry 152 391-397, 1995 Kranzler HR, Burleson JA, Brown J, et al Fluoxetine treatment seems to reduce the beneficial effects of cognitive-behavioral therapy in type B alcoholics. Alcohol Clin Exp Res 20 1534-1341, 1996... 

Streeton C, Whelan G Naltrexone, a relapse prevention maintenance treatment of alcohol dependence a meta-analysis of randomized controlled trials. Alcohol Alcohol 36 544-552, 2001... 

J Consult Clin Psychol 61 1100—1104, 1993 Stephens RS, Roffman RA, Simpson EE Treating adult marijuana dependence a test of the relapse prevention model. J Consult Clin Psychol 62 92—99, 1994 Stephens RS, Roffman RA, Curtin L Comparison of extended versus brief treatments for marijuana use. J Counsul Clin Psychol 68 898—908, 2000 Substance Abuse and Mental Health Services Administration The BASIS Report Marijuana Treatment Admissions Increase 1993-1999. Rockville, MB, Substance Abuse and Mental Health Services Administration, 2002a Substance Abuse and Mental Health Services Administration Results from the 2001 National Household Survey on Brug Abuse Vol I. Summary of National Findings. Rockville, MB, Substance Abuse and Mental Health Services Administration, 2002b... 

More than 40 medications have been investigated but none have shown consistent efficacy for primary cocaine or amphetamine dependence. These medications include dopaminergic agonists, antidepressants, and more recently disulfiram, selegiline, and a cocaine vaccine (see Table 5—2 for summary). Studies have been relatively brief and have focused on abstinence initiation rather than on relapse prevention, but even these modest treatment goals have not been attained. The focus in the discussion that follows is on pharmacotherapies for cocaine dependence, because very few clinical trials have been completed with amphetamine-dependent patients. Furthermore, none of the studies of amphetamine dependence have shown results different from those described for cocaine dependence (Rawson et al. 2002b Srisurapanont et al. 2001). 

Hays JT, Hurt RD, Rigotti NA, et al Sustained-release bupropion for pharmacologic relapse prevention after smoking cessation. Ann Intern Med 135 423 33, 2001 Henningfleld JE Nicotine medications for smoking cessation. N Engl J Med 333 1196-1203, 1995... 

A common belief is that AA discourages use of treatment medications, which are considered crutches However, in a survey of a large sample of AA members, more then one-half of respondents reported that the use of relapse-preventing... 

Disease-modifying therapies are used to decrease the number of relapses, prevent permanent neurologic damage, and prevent disability. 

Relapse prevention skills and strategies the recovering addict should develop a menu of options, a toolbox of coping skills... 

Cognitive-behavioral therapy (CBT) has the specific goal of learning relapse prevention techniques such as having a ready toolbox to deal with cravings and avoidance of triggers that have led to relapses in the past. 

The overall goals in recovery from addiction are the same for all substances and include improved coping skills and relapse prevention. Methods for accomplishing long-term sobriety include both nonpharmacologic and pharmacologic means. 

Recommend individualized drug therapy for acute treatment and relapse prevention based on patient-specific data. 

The primary treatment for relapse prevention is mood-stabilizing agents. 

Mood-stabilizing drugs are considered the primary pharmacotherapy for relapse prevention. Olanzapine and aripiprazole are also approved for maintenance therapy. 

Olanzapine Zyprexa 20, 30 mg Tablets 2.5, 5, 7.5, 10, 5-20 mg/day in 1 or 2 doses combination with lithium or valproate for the acute treatment of mania or mixed states for bipolar I disorder. Olanzapine and aripiprazole are approved for relapse prevention as well as for acute therapy... 

Divalproex sodium is comprised of sodium valproate and valproic acid. The delayed-release and extended-release formulations are converted in the small intestine into valproic add, which is the systemically absorbed form. It was developed as an antiepileptic drug, but also has efficacy for mood stabilization and migraine headaches. It is FDA-approved for the treatment of the manic phase of bipolar disorder. It is generally equal in efficacy to lithium and some other drugs for bipolar mania. It has particular utility in bipolar disorder patients with rapid cycling, mixed mood features, and substance abuse comorbidity. Although not FDA-approved for relapse prevention, studies support this use, and it is widely prescribed for maintenance therapy. Divalproex can be used as monotherapy or in combination with lithium or an antipsychotic drug.31... 

Lamotrigine is effective for the maintenance treatment of bipolar disorder. It is more effective for depression relapse prevention than for mania relapse. Its primary limitation as an acute treatment is the time required for titration to an effective dosage. In addition to maintenance monotherapy, it is sometimes used in combination with lithium or divalproex, although combination with divalproex increases the risk of rash, and lamotrigine dosage adjustment is required.37... 

Taub, E., Steiner, S., Weingarten, E., and Walton, K., Effectiveness of broad spectrum approaches to relapse prevention in severe alcohlism A long term, randomized, controlled trial of Transcendental Meditation, EMG biofeedback and electronic eurotherapy. Special Issue Self-recovery Treating addictions using transcendental meditation and Maharishi Ayur-Veda. Alcoholism Treatment Quarterly 11 (1-2), 187-220, 1994. 

Now there are a number of problems with relapse-prevention studies. One is the fact that many people who are taken off antidepressants experience withdrawal symptoms, which in severe cases can last for months. Some of these withdrawal symptoms - sadness, suicidal thoughts, crying spells, trouble concentrating, irritability, anxiety, agitation and insomnia, for example - are also symptoms of depression.12 These withdrawal symptoms could lead both patients and researchers to think that the patient has relapsed. 

A second problem with relapse-prevention trials is related to research suggesting that the use of antidepressants might make people more vulnerable to relapse. Patients who are being treated... 

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