Final Exam Treatment approaches 2 Flashcards
Two Approaches to Non-Pharmacological Treatments:
behavioral
self-help
___ is often transient and short-lived following adverse events
readiness to change
Behavioral Treatments: motivational interviewing
premise: help clients/patients identify their own intrinsic reasons to change:
-designed to work around “denial” and resistance
-often used in acute settings (e.g., ERs) but techniques are useful elsewhere
effective for:
-reducing alcohol intake among heavy drinkers
-reducing marijuana use
limitations:
-often delivered in single sessions
-despite incredible popularity, efficacy for treating addiction is poor
conclusion: useful, low cost technique but by itself not a viable strategy for treating addiction
Behavioral Treatments: contingency management
premise: reward patients for meeting treatment goals (e.g., clean drug screens)
example: vouchers redeemable for goods and services contingent on cocaine-free urine screens
effective for:
-improving retention and abstinence in outpatient opioid detoxification
-reducing smoking and illicit substance use among opioid addicts in methadone maintenance
-reducing frequency of marijuana use
-improving compliance among opioid-dependent patients treated with naltrexone maintenance
limitations:
-unsustainable in clinical practice
-promotes external attributions of success
-effects weaken/disappear after the contingency is terminated
conclusion: probably a short-term solution to be used as an adjunct to other approaches
Behavioral Treatments: cognitive behavior therapy (CBT)
premise: high risk behaviors (using) and feelings (craving) can be modified through cognitive strategies and restructuring
-automatic, catastrophic thinking and faulty assumptions must be challenged and changed
-examples: cravings do not inevitably lead to using, “play the tape all the way through”
-emphasis on reciprocal feedback among A-B-Cs
Affect: craving, anxiety, excitement
Behavior: drug-seeking
Cognition: hopelessness, resignation
effective for:
-alcohol use disorders
-outpatient treatment of cocaine dependence
-treating depressed cocaine users
-treating benzodiazepine addiction
-increasing effectiveness of certain pharmacotherapies (e.g., disulfiram)
-teaching skills needed for long-term abstinence
-inducing internal attributions of success
limitations:
-requires expert clinicians
-more effective with higher-functioning, educated clients
conclusion: components of CBT (changing attributions, teaching cognitive strategies, changing faulty cognitions) are used in virtually all treatments, including self-help (see below)
__ are easier to change than feelings or behaviors
cognitions
Behavioral Treatments: couples and family therapy
premise: treat addiction by altering the family/social context within which it is embedded
effective for:
reducing attrition
helps participating family members (e.g., improves children’s psychosocial outcomes)
more effective than individual therapy for cocaine and opioid dependence
limitations:
very diverse set of treatments with wide range of efficacy
conclusion: many who are addicted do better when families are included in inpatient, outpatient, aftercare, and extended therapy
By far the most popular self-help approach, founded in 1935 in Akron OH, is __
Alcoholics Anonymous
other programs, including Narcotics Anonymous, Cocaine Anonymous, and AA Agnostica are modeled directly from __
AA
Self-Help: AA
premises:
recovery from addiction requires help of others and adoption of a new way of life
addicts must “surrender” to their addiction, thereby accepting loss of control
addicts should find a “sponsor” with significant clean time to advise them
with their sponsor, addicts should work an active (12-step) program of recovery, including amends to those they’ve hurt
examples:
Traditional 12 Steps:
Secular 12 Steps:
effective for:
encouraging abstinence–estimates suggest the 2 million people are currently abstinent in AA alone (Kasutkas, 2009; Krentzman et al., 2010)
encouraging social networking
recovering from shame
limitations:
less effective for those with comorbid mental health issues (but so is everything else)
off-putting to those who do not believe in “capital G” god and are not made aware of secular groups
some in the scientific community are biased against AA because it (a) is rooted in teachings of a single religion (Christianity; the Oxford Group (Links to an external site.)), and (b) is difficult to study
conclusion: collectively, those who attend AA show better outcomes in a dose-response fashion
True or false: Groups for attorneys (International Lawyers in Alcoholics Anonymous) and physicians and other health professionals (International Doctors in Alcoholics Anonymous), for whom anonymity is often paramount
True
none of these behavioral or self-help treatments take the place of appropriate inpatient detox, inpatient treatment, or outpatient treatment during the ___
acute withdrawal phase
Development of Drug Treatments (3)
- serendipity: the occurrence and development of events by chance in a happy or beneficial way
example: bupropion (Zyban, Wellbutrin), a norepinephrine and dopamine reuptake inhibitor (NDRI), was marketed originally for depression - systematic research with animals ←→ humans
- once approved for human research, drug efficacy is evaluated using clinical trials
clinical trials are defined as
any “prospective study comparing the effects and value of interventions against a control in human beings”
all clinical trials include __ and __ who are followed forward in time (i.e., prospectively) and evaluated/compared for treatment response
intervention
control groups
intervention group vs control group:
intervention group: participants who get the new drug
control group: participants who get a placebo or treatment as usual (TAU)
There are __ phases of clinical trails
four
Before a Phase I clinical trial can begin, the US Food and Drug Administration (FDA) must grant approval for an __
investigational new drug (IND)
Animal models of medication development can be mapped onto the three stages of addiction outlined by Koob et al., 2014. Effects of potential addiction medications can be tested on animals by observing effects on:
- binge/intoxication
- withdrawal/negative affect
- preoccupation/anticipation
Existing Drugs Used to Treat Addiction Among Humans in the (1) binge/intoxication stage:
disulfiram (Antabuse) naltrexone (ReVia, Vivitrol): methadone (Dolophine): buprenorphine (Subutex [Suboxone when naloxone is added]): varenicline (Chantix, Champix): bupropion (Wellbutrin, Zyban):
Existing Drugs Used to Treat Addiction Among Humans in the (2) withdrawal/negative affect stage:
methadone (Dolophine):
buprenorphine (Subutex [Suboxone when naloxone is added]):
nicotine patch:
varenicline (Chantix, Champix):
Existing Drugs Used to Treat Addiction Among Humans in the (3) preoccupation/anticipation stage:
acamprosate (Campral):
bupropion (Wellbutrin, Zyban):
disulfiram (Antabuse):
blocks conversion of acetaldehyde to acetic acid, raising acetaldehyde levels 5-10x over ordinarily levels when metabolizing alcohol alone
very effective in preventing alcohol use if taken
can reduce one’s confidence in ability to abstain
naltrexone (ReVia, Vivitrol):
μ-, δ-, and κ-opioid receptor antagonist
used to treat alcohol and opioid dependence, but for unknown reasons, is more (though not fully) effective with alcohol (see below)
reduces but does not eliminate euphoric properties of use
extended-release injections, which circumvent adherence problems, cost over $1200 per month
methadone (Dolophine):
less potent, longer-acting opioid that heroin
used for substitution (i.e., maintenance) therapy for heroin addiction, and for analgesic effects (pain relief)
carries abuse potential itself including about 5,000 deaths per year in the US
longer withdrawal than heroin
buprenorphine (Subutex [Suboxone when naloxone is added]):
less potent, longer-acting opioid that heroin (and methadone)
naloxone (Narcan) is a μ-opioid and κ-opioid receptor antagonist
buprenorphine is used for maintenance therapy for heroin addiction, and for analgesic effects (pain relief)
partial μ-opioid receptor agonist (other opioids are much stronger)
carries abuse potential itself and risk of respiratory depression and death, especially if paired with benzodiazepines
a black market has developed
much longer withdrawal than heroin (up to one month)
varenicline (Chantix, Champix):
partial α4β2 nicotinic acetylcholine (nACH) receptor agonist
releases dopamine in the nucleus accumbens and can therefore reduce nicotine cravings
potential to increase suicidal ideation; no longer allowed by the Federal Aviation Administration
bupropion (Wellbutrin, Zyban):
norepinephrine and dopamine reuptake inhibitor (NDRI) antidepressant
increases DA levels in the ventral striatum (VS), reduces cravings, and partially blocks the high associated with nicotine and strong stimulants (cocaine, meth)
no psychoactive properties
increases blood pressure and lowers seizure threshold; banned in Europe due to hypertensive effects
nicotine patch:
less potent, longer-acting form of nicotine
heavily marketed
intuitive appeal but unsupervised weaning is more often than not ineffective, regardless of the addictive substance
effectiveness usually assessed by smoking cessation—not addiction to nicotine
varenicline (Chantix, Champix):
partial α4β2 nicotinic acetylcholine (nACH) receptor agonist (see above)
releases dopamine in the nucleus accumbens and can therefore reduce nicotine cravings
acamprosate (Campral):
for treatment of alcohol dependence
glutamate receptor, N-methyl-D-aspartate (NMDA) receptor, and Ca+ channel modulator
works best with people who are motivated to quit drinking
FDA label includes warnings about increases in suicidal behavior, major depressive disorder, and kidney failure
Limitations of Drug Treatments
- effect sizes are modest at best (more often small) and effectiveness is highly overstated by drug companies, who sell to physicians
- rodent models are great for assessing effects of addiction on subcortical functions, but limited for assessing effects of addiction on cortical functions
- IMPORTANT: neither acquisition of nor recovery from addiction can be understood at any single level of analysis, including neurobiology; we live in an era of biological reductionism
IMPORTANT: neither acquisition of nor recovery from addiction can be understood at any single level of analysis, including neurobiology; we live in an era of biological reductionism
emotion is missing from many of our models (and not discussed by Koob et al., 2014)
animal models cannot address the roles that emotion plays in recovery from addiction
-depression
-guilt
-shame
-self-doubt
culture is missing from many of our models (and not discussed by Koob et al., 2014)
-cultural norms
-cultural fallacies
-cultural stigma
