REFERAT

Addiction Treatment : Medical Emergency and Substance Use

DISUSUN OLEH:
Kevin Fidiasrianto

PEMBIMBING:
dr. Dharmadi Agus, Sp.KJ

KEPANITERAAN KLINIK ILMU KEDOKTERAN JIWA

FAKULTAS KEDOKTERAN UNIVERSITAS PELITA HARAPAN
SANATORIUM DHARMAWANGSA
PERIODE 17 Juni 2019 – 19 Juli 2019
JAKARTA SELATAN
 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 Unfortunately, outdated views about drug use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 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.
 CHAPTER 2 : LITERATURE REVIEW

Treatment of substance intoxication

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.
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. 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 of ethanol and isopropanol intoxication is largely supportive. [1] Because of
the 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
[2, 3, 4]
fomepizole. 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 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
[7]
been associated with more frequent adverse reactions than fomepizole. 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

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.

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 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
Treatment of substance withdrawal

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.
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
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
 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, 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.
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 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
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.

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.

PHARMACOTHERAPIES

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

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.

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
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.

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 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 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.
 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.
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