CHAPTER 1 : INTRODUCTION

About 275 million people worldwide (5.6 per cent of the global population aged
15–64 years) used drugs at least once during 2016. Overdose deaths contribute to
between roughly a third and a half of all drug-related deaths. Approximately one in ten
people who use illicit drugs is suffering from a form of a drug use disorder, including
drug dependence. Almost half of people with drug dependence inject drugs and of them
more than 10% are living with HIV, and the majority are infected with hepatitis C.
Drug use disorders are a major global health problem. Drug use disorders are a serious
health issue, with a significant burden for individuals affected and their families. There
are also significant costs to society including lost productivity, security challenges,
crime, increased health care costs, and a myriad of negative social consequences. The
social cost of illicit drug use is estimated at up to 1.7% of GDP in some countries
(World Drug Report, 2016). Caring for individuals with drug use disorders places a
heavy burden on public health systems of Member States and therefore improving
treatment systems by making them the best they can be. This would undoubtedly
benefit not only the affected individuals, but also their communities and the whole
society. Unfortunately, outdated views about drug use disorders persist in many parts
of the world. Stigma and discrimination that is commonly applied to drug dependent
individuals and to professionals working with them have significantly compromised
the implementation of quality treatment interventions in this area, undermining the
development of treatment facilities, the training of health professionals and the
investment in recovery programs. Even though the evidence clearly shows that drug
use disorders are best managed within a public health system, similarly to other medical
problems such as HIV infection or hypertension, the inclusion of addiction treatment
in the health care system is still very difficult in many countries where a huge gap exists
between science, policy and the clinical practice. In some countries drug use disorders
are still seen as a primarily criminal justice problem, and agencies of the Ministry of

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Interior, Ministry of Justice or Ministry of Defense are still responsible for affected
individuals, without the supervision or engagement of the Ministry of Health. Using
only law enforcement strategies and methods is unlikely to result in sustained positive
effects. Only treatment that has at its core an understanding of drug dependence as a
primarily multifactorial biological and behavioral disorder, that can be treated using
medical and psychological approaches, can improve chances of a recovery from the
disorder and reduce (drug-) related consequences.

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 CHAPTER 2 : LITERATURE REVIEW

2.1 Treatment of substance intoxication

2.1.1 Opioid

Opioid overdose

Due to their effect on the part of the brain which regulates breathing, opioids in high
doses can cause respiratory depression and death. An opioid overdose can be identified
by a combination of three signs and symptoms referred to as the “opioid overdose
triad”. The symptoms of the triad are:

 pinpoint pupils
 unconsciousness
 respiratory depression.

Combining opioids with alcohol and sedative medication increases the risk of
respiratory depression and death, and combinations of opioids, alcohol and sedatives
are often present in fatal drug overdoses.

Because of their capacity to cause respiratory depression, opioids are responsible for a
high proportion of fatal drug overdoses around the world. The number of opioid
overdoses has increased in recent years, in part due to the increased use of opioids in
the management of chronic non-cancer pain. In the United States of America alone in
2016, there were an estimated 63 632 deaths due to drug overdose, which is a 21%
increase from previous years. This was largely due to a rise in deaths associated with
prescription opioids. This group of opioids (excluding methadone) was implicated in
19 413 deaths in the country, more than double the number in 2015.

3
Emergency responses to opioid overdose

Death following opioid overdose is preventable if the person receives basic life support
and the timely administration of the opioid antagonist naloxone. Naloxone, which is
effectively an antidote to opioid overdose, will completely reverse the effects of an
opioid overdose if administered in time. Naloxone is effective when delivered by
intravenous, intramuscular, subcutaneous, and intranasal routes of administration.
Naloxone has virtually no effect in people who have not taken opioids.

Access to naloxone is generally limited to health professionals. In many countries there

is still limited availability of naloxone even in medical settings, including ambulances.
At least one country, Italy, has already made naloxone available in pharmacies without
prescription.

Since most overdoses are witnessed by a friend or family member, if a friend or family
member had access to naloxone, he or she may be able to reverse the effects of opioid
overdose, while waiting for medical care to arrive. While naloxone administered by
bystanders is a potentially life-saving emergency interim response to opioid overdose,
it should not be seen as a replacement for comprehensive medical care.

2.1.2 Alcohol

Emergency Department Care

As with all emergency patients, initial treatment should focus on the airway,
breathing, and circulation. Gastric decontamination is rarely necessary for any of the
alcohols. An exception to this may be a patient who presents immediately after
ingestion of a toxic alcohol in whom one might reasonably expect to be able to recover
a significant amount of the toxin via aspiration through a nasogastric tube. Treatment
[1]
of ethanol and isopropanol intoxication is largely supportive. Because of the

4
hemorrhagic gastritis that can follow isopropanol ingestion, H2 blockade or proton-
pump inhibitors may be helpful. Hemodialysis, while effective, is rarely indicated, and
should only be used in the setting of profound hemodynamic compromise. [9]

Once either methanol or ethylene glycol intoxication are suspected, treatment

should be initiated without delay. Fortunately, since both alcohols are metabolized by
alcohol dehydrogenase, the treatment is the same, and differentiating which of the two
toxic alcohols is responsible is not necessary before implementing treatment. [1] The
primary antidotal treatment of methanol or ethylene glycol involves blocking alcohol
dehydrogenase. This enzyme can be inhibited by either ethanol or fomepizole. [2, 3, 4]
Toxic alcohol levels are frequently not immediately available. Thus, ideally, if
methanol or ethylene glycol poisoning is suspected, the patient should receive a loading
dose of fomepizole while the levels are being obtained. Because the next dose of
fomepizole is not due for an additional 12 hours, this strategy allows 12 hours for the
blood to be processed at a reference laboratory before additional treatment is needed.

Inhibition of alcohol dehydrogenase with ethanol may be substituted for

treatment with fomepizole, though studies have highlighted the greater safety of
[10]
fomepizole as a treatment, when available. In some patients, treatment with
fomepizole alone may represent definitive treatment and can prevent the need for
hemodialysis. [5]

In addition to blocking alcohol dehydrogenase, significant metabolic acidosis

should be treated with sodium bicarbonate infusions. If methanol is suspected, folinic
acid should be administered at a dose of 1 mg/kg, with a maximal dose of 50 mg. It
should be repeated every 4 hours. If folinic acid is not immediately available, folic acid
can be substituted at the same dose.

If ethylene glycol overdose is suspected, the patient should also receive 100 mg
of intravenous thiamine every 6 hours and 50 mg of pyridoxine every 6 hours. The

5
purpose of the thiamine and pyridoxine is to shunt metabolism of glyoxylic acid away
from oxalate and favor the formation of less toxic metabolites.

In methanol overdose, sodium bicarbonate should be administered liberally,

with the goal being to completely reverse the acidosis. Experimental studies suggest
that formate is excreted in the kidneys at a much higher rate when the patient is not
acidotic. In addition, when the patient is not acidotic, formic acid dissociates to formate
at lower rates so that less formate crosses the blood-brain barrier. Thus, in methanol
intoxication, correcting the acidosis actually speeds up elimination of the toxic
compound and decreases toxicity.

If ethanol is used as an antidote, the recommended target serum concentration

is 100-150 mg/dL. Because ethanol inhibits gluconeogenesis, hypoglycemia is
common in patients on an ethanol infusion. [6] Hypoglycemia is particularly prevalent
in pediatric patients on such drips. Thus, serum glucose levels must be checked
frequently, at least every 2 hours. In addition, because it is difficult to attain a steady
serum concentration of ethanol, the ethanol level also must be checked frequently, and
titrations made. A 5% or 10% ethanol solution can be made in the pharmacy. If giving
ethanol, administer a loading dose of 600 mg/kg, followed by a drip of 66-154 mg/kg/h,
with chronic alcoholics requiring doses at the higher end of the scale. Ethanol can be
given either intravenously or orally.

In addition to hypoglycemia, additional adverse effects from ethanol infusion include

inebriation, CNS depression, pancreatitis, and local phlebitis. Because of the phlebitis
that occurs with ethanol infusions, some advocate that ethanol should only be
administered via a central venous line.

Ethanol infusions are not only labor intensive, but once the costs of the frequent
blood glucose and serum ethanol level assays are accounted for, ethanol antidotal
therapy is frequently more expensive than fomepizole. Ethanol has also been associated

6
with more frequent adverse reactions than fomepizole. [7] Thus, because of the lower
overall cost and the ease of administration and safety considerations, fomepizole has
become the preferred antidote for methanol or ethylene glycol poisoning. [8]

Fomepizole should be administered as a loading dose of 15 mg/kg. Subsequent

doses should be at 10 mg/kg every 12 hours for 4 doses. Because fomepizole actually
induces its own metabolism after 48 hours of treatment, if additional doses are needed,
the dose should be increased to 15 mg/kg. Fomepizole needs to be re-dosed during
hemodialysis. The package insert or local poison center can help with the re-dosing
strategy. Fomepizole should be continued until the serum ethylene glycol or methanol
concentrations are less than 20 mg/dL.

Hemodialysis is frequently required in patients with significant methanol or ethylene

glycol ingestions. [1, 5] Indications for hemodialysis include the following:

 Arterial pH < 7.10

 A decline of >0.05 in the arterial pH despite bicarbonate infusion
 pH < 7.3 despite bicarbonate therapy
 Rise in serum creatinine level by 90 mmol/L
 Initial plasma methanol or ethylene glycol concentration ≥50 mg/dL

2.1.3 Ecstasy/ Molly (MDMA)

3,4-methylenedioxy-methamphetamine (MDMA) is a synthetic drug that alters mood
and perception (awareness of surrounding objects and conditions). It is chemically
similar to both stimulants and hallucinogens, producing feelings of increased energy,
pleasure, emotional warmth, and distorted sensory and time perception. MDMA was
initially popular in the nightclub scene and at all-night dance parties ("raves"), but the
drug now affects a broader range of people who more commonly call the drug Ecstasy
or Molly.

7
Signs and symptoms of MDMA intoxication manifest across multiple body systems
and includes :

 Uncontrolled body movements.

 Confusion and other changes in mental status.
 Restlessness and anxiety, even paranoia.
 Headache and blurred vision.
 Clenched jaws.
 Elevated body temperature, chills, and excessive sweating.
 Abdominal cramping, nausea, and vomiting.
 Irregular and rapid heart rate along with chest pains.
 Increased blood pressure.
 Urinary retention and delayed orgasm.

Overdose of ecstasy is indicated when these symptoms advance in intensity and

dangerous conditions emerge, including renal failure and cardiac arrhythmias. Other
symptoms of an overdose include 2:

 Hyperthermia—a dangerous overheating of the body.

 Very high blood pressure.
 Fainting spells.
 Loss of consciousness.
 Seizures.
 Panic attacks.

Emergency Department Care

Physicians may administer activated charcoal to neutralize any drugs remaining

in the stomach. They quickly address such emergency medical conditions as elevated
blood pressure, high body temperatures, and cardiac issues. Once stabilized and

8
depending on a host of factors, a person may be admitted for medical treatment,
transferred to a drug detox or treatment facility or discharged with a referral to
supportive services

9
2.2 Treatment of substance withdrawal

2.2.1 The Transtheoretical Model (Stages of changes)

The Transtheoretical Model (also called the Stages of Change Model),

developed by Prochaska and DiClemente in the late 1970s, evolved through studies
examining the experiences of smokers who quit on their own with those requiring
further treatment to understand why some people were capable of quitting on their own.
It was determined that people quit smoking if they were ready to do so. Thus, the
Transtheoretical Model (TTM) focuses on the decision-making of the individual and is
a model of intentional change. The TTM operates on the assumption that people do not
change behaviors quickly and decisively. Rather, change in behavior, especially
habitual behavior, occurs continuously through a cyclical process. The TTM is not a
theory but a model; different behavioral theories and constructs can be applied to
various stages of the model where they may be most effective.

The TTM posits that individuals move through six stages of change:
precontemplation, contemplation, preparation, action, maintenance, and termination.
Termination was not part of the original model and is less often used in application of
stages of change for health-related behaviors. For each stage of change, different
intervention strategies are most effective at moving the person to the next stage of
change and subsequently through the model to maintenance, the ideal stage of behavior.

1. Precontemplation - In this stage, people do not intend to take action in the

foreseeable future (defined as within the next 6 months). People are often
unaware that their behavior is problematic or produces negative consequences.
People in this stage often underestimate the pros of changing behavior and place
too much emphasis on the cons of changing behavior.

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2. Contemplation - In this stage, people are intending to start the healthy behavior
in the foreseeable future (defined as within the next 6 months). People
recognize that their behavior may be problematic, and a more thoughtful and
practical consideration of the pros and cons of changing the behavior takes
place, with equal emphasis placed on both. Even with this recognition, people
may still feel ambivalent toward changing their behavior.
3. Preparation (Determination) - In this stage, people are ready to take action
within the next 30 days. People start to take small steps toward the behavior
change, and they believe changing their behavior can lead to a healthier life.
4. Action - In this stage, people have recently changed their behavior (defined as
within the last 6 months) and intend to keep moving forward with that behavior
change. People may exhibit this by modifying their problem behavior or
acquiring new healthy behaviors.
5. Maintenance - In this stage, people have sustained their behavior change for a
while (defined as more than 6 months) and intend to maintain the behavior
change going forward. People in this stage work to prevent relapse to earlier
stages.
6. Termination - In this stage, people have no desire to return to their unhealthy
behaviors and are sure they will not relapse. Since this is rarely reached, and
people tend to stay in the maintenance stage, this stage is often not considered
in health promotion programs.
7. Relapse – if not, The person falls back into old patterns of behavior

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2.2.2 PRINCIPLES OF EFFECTIVE TREATMENT

1. Addiction is a complex but treatable disease that affects brain function and
behavior. Drugs of abuse alter the brain’s structure and function, resulting in
changes that persist long after drug use has ceased. This may explain why drug
abusers are at risk for relapse even after long periods of abstinence and despite
the potentially devastating consequences.
2. No single treatment is appropriate for everyone. Treatment varies
depending on the type of drug and the characteristics of the patients. Matching

12
 treatment settings, interventions, and services to an individual’s particular
problems and needs is critical to his or her ultimate success in returning to
productive functioning in the family, workplace, and society.
3. Treatment needs to be readily available. Because drug-addicted individuals
may be uncertain about entering treatment, taking advantage of available
services the moment people are ready for treatment is critical. Potential patients
can be lost if treatment is not immediately available or readily accessible. As
with other chronic diseases, the earlier treatment is offered in the disease
process, the greater the likelihood of positive outcomes.
4. Effective treatment attends to multiple needs of the individual, not just his
or her drug abuse. To be effective, treatment must address the individual’s
drug abuse and any associated medical, psychological, social, vocational, and
legal problems. It is also important that treatment be appropriate to the
individual’s age, gender, ethnicity, and culture.
5. Remaining in treatment for an adequate period of time is critical. The
appropriate duration for an individual depends on the type and degree of the
patient’s problems and needs. Research indicates that most addicted individuals
need at least 3 months in treatment to significantly reduce or stop their drug use
and that the best outcomes occur with longer durations of treatment. Recovery
from drug addiction is a long-term process and frequently requires multiple
episodes of treatment. As with other chronic illnesses, relapses to drug abuse
can occur and should signal a need for treatment to be reinstated or adjusted.
Because individuals often leave treatment prematurely, programs should
include strategies to engage and keep patients in treatment.
6. Behavioral therapies—including individual, family, or group counseling—
are the most commonly used forms of drug abuse treatment. Behavioral
therapies vary in their focus and may involve addressing a patient’s motivation
to change, providing incentives for abstinence, building skills to resist drug use,
replacing drug-using activities with constructive and rewarding activities,

13
 improving problem-solving skills, and facilitating better interpersonal
relationships. Also, participation in group therapy and other peer support
programs during and following treatment can help maintain abstinence.
7. Medications are an important element of treatment for many patients,
especially when combined with counseling and other behavioral
therapies. For example, methadone, buprenorphine, and naltrexone (including
a new long-acting formulation) are effective in helping individuals addicted to
heroin or other opioids stabilize their lives and reduce their illicit drug use.
Acamprosate, disulfiram, and naltrexone are medications approved for treating
alcohol dependence. For persons addicted to nicotine, a nicotine replacement
product (available as patches, gum, lozenges, or nasal spray) or an oral
medication (such as bupropion or varenicline) can be an effective component
of treatment when part of a comprehensive behavioral treatment program.
8. An individual's treatment and services plan must be assessed continually
and modified as necessary to ensure that it meets his or her changing
needs. A patient may require varying combinations of services and treatment
components during the course of treatment and recovery. In addition to
counseling or psychotherapy, a patient may require medication, medical
services, family therapy, parenting instruction, vocational rehabilitation, and/or
social and legal services. For many patients, a continuing care approach
provides the best results, with the treatment intensity varying according to a
person’s changing needs.
9. Many drug-addicted individuals also have other mental
disorders. Because drug abuse and addiction—both of which are mental
disorders—often co-occur with other mental illnesses, patients presenting with
one condition should be assessed for the other(s). And when these problems co-
occur, treatment should address both (or all), including the use of medications
as appropriate.

14
10. Medically assisted detoxification is only the first stage of addiction
treatment and by itself does little to change long-term drug
abuse. Although medically assisted detoxification can safely manage the acute
physical symptoms of withdrawal and can, for some, pave the way for effective
long-term addiction treatment, detoxification alone is rarely sufficient to help
addicted individuals achieve long-term abstinence. Thus, patients should be
encouraged to continue drug treatment following detoxification. Motivational
enhancement and incentive strategies, begun at initial patient intake, can
improve treatment engagement.
11. Treatment does not need to be voluntary to be effective. Sanctions or
enticements from family, employment settings, and/or the criminal justice
system can significantly increase treatment entry, retention rates, and the
ultimate success of drug treatment interventions.
12. Drug use during treatment must be monitored continuously, as lapses
during treatment do occur. Knowing their drug use is being monitored can
be a powerful incentive for patients and can help them withstand urges to use
drugs. Monitoring also provides an early indication of a return to drug use,
signaling a possible need to adjust an individual’s treatment plan to better meet
his or her needs.
13. Treatment programs should test patients for the presence of HIV/AIDS,
hepatitis B and C, tuberculosis, and other infectious diseases as well as
provide targeted risk-reduction counseling, linking patients to treatment if
necessary. Typically, drug abuse treatment addresses some of the drug-related
behaviors that put people at risk of infectious diseases. Targeted counseling
focused on reducing infectious disease risk can help patients further reduce or
avoid substance-related and other high-risk behaviors. Counseling can also help
those who are already infected to manage their illness. Moreover, engaging in
substance abuse treatment can facilitate adherence to other medical treatments.
Substance abuse treatment facilities should provide onsite, rapid HIV testing

15
 rather than referrals to offsite testing—research shows that doing so increases
the likelihood that patients will be tested and receive their test results.
Treatment providers should also inform patients that highly active antiretroviral
therapy (HAART) has proven effective in combating HIV, including among
drug-abusing populations, and help link them to HIV treatment if they test
positive.

Drug addiction treatment can include medications, behavioral therapies, or their

combination. Treatment medications, such as methadone, buprenorphine, and
naltrexone (including a new long-acting formulation), are available for individuals
addicted to opioids, while nicotine preparations (patches, gum, lozenges, and nasal
spray) and the medications varenicline and bupropion are available for individuals

16
addicted to tobacco. Disulfiram, acamprosate, and naltrexone are medication available
for treating alcohol dependence, which commonly co-occurs with other drug
addictions, including addiction to prescription medications.

Treatments for prescription drug abuse tend to be similar to those for illicit drugs
that affect the same brain systems. For example, buprenorphine, used to treat heroin
addiction, can also be used to treat addiction to opioid pain medications. Addiction to
prescription stimulants, which affect the same brain systems as illicit stimulants like
cocaine, can be treated with behavioral therapies, as there are not yet medications for
treating addiction to these types of drugs.

Behavioral therapies can help motivate people to participate in drug treatment,

offer strategies for coping with drug cravings, teach ways to avoid drugs and prevent
relapse, and help individuals deal with relapse if it occurs. Behavioral therapies can
also help people improve communication, relationship, and parenting skills, as well as
family dynamics.

Many treatment programs employ both individual and group therapies. Group
therapy can provide social reinforcement and help enforce behavioral contingencies
that promote abstinence and a non-drug-using lifestyle. Some of the more established
behavioral treatments, such as contingency management and cognitive-behavioral
therapy, are also being adapted for group settings to improve efficiency and cost-
effectiveness. However, particularly in adolescents, there can also be a danger of
unintended harmful (or iatrogenic) effects of group treatment—sometimes group
members (especially groups of highly delinquent youth) can reinforce drug use and
thereby derail the purpose of the therapy. Thus, trained counselors should be aware of
and monitor for such effects. Because they work on different aspects of addiction,
combinations of behavioral therapies and medications (when available) generally
appear to be more effective than either approach used alone.

17
 Finally, people who are addicted to drugs often suffer from other health (e.g.,
depression, HIV), occupational, legal, familial, and social problems that should be
addressed concurrently. The best programs provide a combination of therapies and
other services to meet an individual patient’s needs. Psychoactive medications, such as
antidepressants, anti-anxiety agents, mood stabilizers, and antipsychotic medications,
may be critical for treatment success when patients have co-occurring mental disorders
such as depression, anxiety disorders (including post-traumatic stress disorder), bipolar
disorder, or schizophrenia. In addition, most people with severe addiction abuse
multiple drugs and require treatment for all substances abused.

2.3 PHARMACOTHERAPIES

2.3.1 Opioid Addiction

1. Methadone is a long-acting synthetic opioid agonist medication that can prevent

withdrawal symptoms and reduce craving in opioid-addicted individuals. It can
also block the effects of illicit opioids. It has a long history of use in treatment
of opioid dependence in adults and is taken orally. Methadone maintenance
treatment is available in all but three States through specially licensed opioid
treatment programs or methadone maintenance programs. Combined with
behavioral treatment Research has shown that methadone maintenance is more
effective when it includes individual and/or group counseling, with even better
outcomes when patients are provided with, or referred to, other needed
medical/psychiatric, psychological, and social services (e.g., employment or
family services).
2. Buprenorphine is a synthetic opioid medication that acts as a partial agonist at
opioid receptors—it does not produce the euphoria and sedation caused by
heroin or other opioids but is able to reduce or eliminate withdrawal symptoms
associated with opioid dependence and carries a low risk of overdose.

18
 Buprenorphine is currently available in two formulations that are taken
sublingually: (1) a pure form of the drug and (2) a more commonly prescribed
formulation called Suboxone, which combines buprenorphine with the drug
naloxone, an antagonist (or blocker) at opioid receptors. Naloxone has no effect
when Suboxone is taken as prescribed, but if an addicted individual attempts to
inject Suboxone, the naloxone will produce severe withdrawal symptoms.
Thus, this formulation lessens the likelihood that the drug will be abused or
diverted to others.

3. Naltrexone is a synthetic opioid antagonist—it blocks opioids from binding to

their receptors and thereby prevents their euphoric and other effects. It has been
used for many years to reverse opioid overdose and is also approved for treating
opioid addiction. The theory behind this treatment is that the repeated absence
of the desired effects and the perceived futility of abusing opioids will gradually
diminish craving and addiction. Naltrexone itself has no subjective effect
following detoxification (that is, a person does not perceive any particular drug
effect), it has no potential for abuse, and it is not addictive. Naltrexone as a
treatment for opioid addiction is usually prescribed in outpatient medical
settings, although the treatment should begin after medical detoxification in a
residential setting in order to prevent withdrawal symptoms. Naltrexone must
be taken orally—either daily or three times a week—but noncompliance with
treatment is a common problem. Many experienced clinicians have found
naltrexone best suited for highly motivated, recently detoxified patients who
desire total abstinence because of external circumstances—for instance,
professionals or parolees. Recently, a long-acting injectable version of
naltrexone, called Vivitrol, was approved to treat opioid addiction. Because it
only needs to be delivered once a month, this version of the drug can facilitate

19
 compliance and offers an alternative for those who do not wish to be placed on
agonist/partial agonist medications.

2.3.2 Tobacco Addiction

1. Nicotine Replacement Therapy (NRT) A variety of formulations of nicotine
replacement therapies (NRTs) now exist, including the transdermal nicotine
patch, nicotine spray, nicotine gum, and nicotine lozenges. Because nicotine
is the main addictive ingredient in tobacco, the rationale for NRT is that
stable low levels of nicotine will prevent withdrawal symptoms—which
often drive continued tobacco use—and help keep people motivated to quit.
Research shows that combining the patch with another replacement therapy
is more effective than a single therapy alone
2. Bupropion (Zyban®) was originally marketed as an antidepressant
(Wellbutrin). It produces mild stimulant effects by blocking the reuptake of
certain neurotransmitters, especially norepinephrine and dopamine. A
serendipitous observation among depressed patients was that the
medication was also effective in suppressing tobacco craving, helping them
quit smoking without also gaining weight. Although bupropion’s exact
mechanisms of action in facilitating smoking cessation are unclear, it has
FDA approval as a smoking cessation treatment.
3. Varenicline (Chantix®) is the most recently FDA-approved medication for
smoking cessation. It acts on a subset of nicotinic receptors in the brain
thought to be involved in the rewarding effects of nicotine. Varenicline acts
as a partial agonist/antagonist at these receptors this means that it midly
stimulates the nicotine receptor but not sufficiently to trigger the release of
dopamine, which is important for the rewarding effects of nicotine. As an
antagonist, varenicline also blocks the ability of nicotine to activate
dopamine, interfering with the reinforcing effects of smoking, thereby
reducing cravings and supporting abstinence from smoking.

20
2.3.3 Alcohol Addiction
1. Naltrexone blocks opioid receptors that are involved in the rewarding
effects of drinking and the craving for alcohol. It has been shown to
reduce relapse to problem drinking in some patients. An extended
release version, Vivitrol—administered once a month by injection—is
also FDA-approved for treating alcoholism, and may offer benefits
regarding compliance
2. Acamprosate (Campral®) acts on the gamma-aminobutyric acid
(GABA) and glutamate neurotransmitter systems and is thought to
reduce symptoms of protracted withdrawal, such as insomnia, anxiety,
restlessness, and dysphoria. Acamprosate has been shown to help
dependent drinkers maintain abstinence for several weeks to months,
and it may be more effective in patients with severe dependence.
3. Disulfiram (Antabuse) interferes with degradation of alcohol, resulting
in the accumulation of acetaldehyde, which, in turn, produces a very
unpleasant reaction that includes flushing nausea, and palpitations if a
person drinks alcohol. The utility and effectiveness of disulfiram are
considered limited because compliance is generally poor. However,
among patients who are highly motivated, disulfiram can be effective
and some patients use it episodically for high-risk situations, such as
social occasions where alcohol is present. It can also be administered in
a monitored fashion, such as in a clinic or by a spouse, improving its
efficancy.
4. Topiramate is thought to work by increasing inhibitory (GABA)
neurotransmission and reducing stimulatory (glutamate)
neurotransmission, although its precise mechanism of action is not
known. Although topiramate has not yet received FDA approval for

21
 treating alcohol addiction, it is sometimes used off-label for this
purpose. Topiramate has been shown in studies to significantly improve
multiple drinking outcomes, compared with a placebo.

2.4 BEHAVIORAL THERAPIES

Behavioral approaches help engage people in drug abuse treatment,

provide incentives for them to remain abstinent, modify their attitudes and
behaviors related to drug abuse, and increase their life skills to handle stressful
circumstances and environmental cues that may trigger intense craving for
drugs and prompt another cycle of compulsive abuse. Below are a number of
behavioral therapies shown to be effective in addressing substance abuse
(effectiveness with particular drugs of abuse is denoted in parentheses).

1. Cognitive-Behavioral Therapy (Alcohol, Marijuana, Cocaine,

Methamphetamine, Nicotine) Cognitive-Behavioral Therapy (CBT) was
developed as a method to prevent relapse when treating problem drinking, and
later it was adapted for cocaine-addicted individuals. Cognitive-behavioral
strategies are based on the theory that in the development of maladaptive
behavioral patterns like substance abuse, learning processes play a critical role.
Individuals in CBT learn to identify and correct problematic behaviors by
applying a range of different skills that can be used to stop drug abuse and to
address a range of other problems that often co-occur with it. A central element
of CBT is anticipating likely problems and enhancing patients’ self-control by
helping them develop effective coping strategies. Specific techniques include
exploring the positive and negative consequences of continued drug use, self-
monitoring to recognize cravings early and identify situations that might put
one at risk for use, and developing strategies for coping with cravings and
avoiding those high-risk situations. Research indicates that the skills individuals

22
 learn through cognitive-behavioral approaches remain after the completion of
treatment. Current research focuses on how to produce even more powerful
effects by combining CBT with medications for drug abuse and with other types
of behavioral therapies. A computer-based CBT system has also been
developed and has been shown to be effective in helping reduce drug use
following standard drug abuse treatment
2. Contingency Management Interventions/Motivational Incentives (Alcohol,
Stimulants, Opioids, Marijuana, Nicotine) Research has demonstrated the
effectiveness of treatment approaches using contingency management (CM)
principles, which involve giving patients tangible rewards to reinforce positive
behaviors such as abstinence. Studies conducted in both methadone programs
and psychosocial counseling treatment programs demonstrate that incentive-
based interventions are highly effective in increasing treatment retention and
promoting abstinence from drugs.
- Voucher-Based Reinforcement (VBR) augments other community-based
treatments for adults who primarily abuse opioids (especially heroin) or
stimulants (especially cocaine) or both. In VBR, the patient receives a
voucher for every drug-free urine sample provided. The voucher has
monetary value that can be exchanged for food items, movie passes, or other
goods or services that are consistent with a drug-free lifestyle. The voucher
values are low at first, but increases. VBR has been shown to be effective
in promoting abstinence from opioids and cocaine in patients undergoing
methadone detoxification.
- Prize Incentives CM applies similar principles as VBR but uses chances to
win cash prizes instead of vouchers. Over the course of the program (at least
3 months, one or more times weekly), participants supplying drug-negative
urine or breath tests draw from a bowl for the chance to win a prize worth
between $1 and $100. Participants may also receive draws for attending
counseling sessions and completing weekly goal-related activities. The

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 number of draws starts at one and increases with consecutive negative drug
tests and/or counseling sessions attended but resets to one with any drug-
positive sample or unexcused absence. The practitioner community has
raised concerns that this intervention could promote gambling—as it
contains an element of chance—and that pathological gambling and
substance use disorders can be comorbid. However, studies examining this
concern found that Prize Incentives CM did not promote gambling behavior.
3. Motivational Enhancement Therapy (Alcohol, Marijuana, Nicotine)
Motivational Enhancement Therapy (MET) is a counseling approach that helps
individuals resolve their ambivalence about engaging in treatment and stopping
their drug use. This approach aims to evoke rapid and internally motivated
change, rather than guide the patient stepwise through the recovery process.
This therapy consists of an initial assessment battery session, followed by two
to four individuals treatment sessions with a therapist. In the first treatment
session, the therapist provides feedback to the initial assessment, stimulating
discussion about personal substance use and eliciting self-motivational
statements. Motivational interviewing principles are used to strengthen
motivation and build a plan for change. Coping strategies for high-risk
situations are suggested and discussed with the patient. In subsequent sessions,
the therapist monitors change, reviews cessation strategies being used, and
continues to encourage commitment to change or sustained abstinence. Patients
sometimes are encouraged to bring a significant other to sessions.

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 CHAPTER 3 : CONCLUSSION

Addiction treatment depends on the situation of the patients, whether

the patients is in the intoxication or withdrawal. The aim of the treatment is
different between the two conditions. When patients is having intoxication or
in the conditions of overdose, the goal of the treatment is to manage the vital
sign (heart rate, respiratory rate, blood pressure, temperature). In this case the
condition is more acute and must be considered as an emergency status.
The aim of the treatment of the withdrawal is to control and avoid
relapse for using the substance again. Drugs that used in the treatment are only
to helps so that it will be easier for the patients to go through the withdrawal
symptoms. Different from the intoxication symptoms, this condition is more
chronic and takes time to resolve. Also needed to remember that relapse can
happen anytime, no matter how long the patient free from using the substance,
but relapse can still be happen, until the patient die.

25
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