Substance-Use Disorders

Glassification of Substance-Related Disorders. The DSM-IV classification system (1) divides substance-related disorders into two categories (/) substance use disorders, ie, abuse and dependence and (2) substance-induced disorders, intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. The different classes of substances addressed herein are alcohol, amphetamines, caffeine, caimabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics or anxiolytics, polysubstance, and others. On the basis of their significant socioeconomic impact, alcohol, nicotine, cocaine, and opioids have been selected for discussion herein. 

Future Outlook for Pharmacologic Treatment of Abuse and Dependence. The importance of the psychosocial dimension ia predisposiag iadividuals toward substance use disorders and subsequentiy maintaining the disorder caimot be overestimated. Additionally, genetic influences have been found to exert an important influence on HabiUty for dmg abuse. A high comorbidity of psychiatric illnesses with substance use disorders further compHcates therapeutic iaterventions ia such patients (236). 

The authors concluded that antidepressants exert a modest beneficial effect for patients with combined depressive disorder and substance use disorder. They also emphasized that antidepressants are not a stand-alone treatment for depressed alcoholic patients and that concurrent therapy directly targeting the substance use disorder is also indicated. 

Grant BF, Stinson FS, Dawson DA, et al Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 61 807-816, 2004b... 

Ciraulo DA, Piechniczek-Buczek J, Iscan EN Outcome predictors in substance use disorders. Psychiatr Clin N Am 26 381 09, 2003... 

Herrington RE, BenzerDG, Jacobson GR, etal Treating substance use disorders among physicians. JAMA 247 2253-2237, 1982... 

Addington J, el-Guebaly N, Campbell W, et al Smoking cessation treatment for patients with schizophrenia. Am J Psychiatry 135 974-976, 1998 American Psychiatric Association Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd Edition. Washington, DC, American Psychiatric Association (in press)... 

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. 

A number of psychosocial treatments for alcohol and other substance use disorders exist and are widely used. In this chapter, we discuss six of these psychotherapies as they are applied to alcohol, cocaine, and opioid dependence brief interventions, motivational enhancement therapy, cognitive-behavioral therapy, behavioral treatments (including contingency management and community reinforcement approaches), behavioral marital therapy, and 12-step facilitation. We also describe studies that examined the efficacy of a medication in combination with one or more of the six psychotherapies. In the second section of the chapter, we highlight research that directly studied the interaction between psychosocial and pharmacological treatments. 

A number of randomized chnical trials have demonstrated the efficacy of CBT for treating substance use disorders, compared with no-treatment control conditions (see Carroll 1996 for review). However, the superiority of CBT over other psychosocial treatments is not as clear. Although some studies have found CBT to be more effective than other treatments, others have found this method to be comparable to other treatment approaches (Carroll 1996). In Project MATCH, for instance, CBT, MET, and 12-step facihtation produced similar outcomes, with each therapy leading to substantial improvement in alcohol-related symptoms during the 12-week treatment period (Project MATCH Research Group 1997). 

In other substance use disorders, the use of 12-step interventions is also popular, and participation in 12-step groups is correlated with better outcomes in cocaine abusers (e.g., McKay et al. 1994). However, a smdy of 128 cocaine abusers found that cognitive-behavioral therapy was more efficacious than 12-step facilitation in engendering cocaine abstinence (Maude-Griffm et al. 1998). Thus, the relative efficacy of 12-step approaches for drug use disorders requires further investigation. No known studies have systematically evaluated the efficacy of 12-step treatments in opioid-dependent patients, either alone or in conjunction with pharmacotherapies. 

Several CM studies have explored interactions between medication and psychosocial treatments for substance use disorders. In a 12-week randomized, double-blind study of buprenorphine-maintained opioid- and cocaine-dependent patients, Kosten et al. (2003a) found that desipramine and CM together led to greater abstinence from cocaine and heroin and more consecutive weeks of abstinence than either treatment individually or placebo. A later... 

Much less attention has been paid to chronic PCP use per se, i.e., the substance use disorder itself. Such issues as the effects of chronic PCP use, and the diagnosis, clinical characterization, and treatment of chronic PCP abusers are rarely discussed in the published literature, even in detailed review articles (Davis 1982 Pearlson 1981 Pradhan 1984). This paper reviews the literature on inpatient and outpatient treatment of PCP abuse, outlines our own experience with PCP users and abusers in one large, public, urban hospital, and makes suggestions for future research based on this information and animal research findings (Balster, this volume). 

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