____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
One medication that reduces craving for alcohol by targeting dopamine is naltrexone (SAMHSA & NIAAA, 2020). Another medication that assists with cravings is acamprosate (brand name Campral), which reduces distress and is thought to help people with an alcohol use disorder (AUD), resist the urge to drink (National Institutes of Health, 2020; SAMHSA, 2022a). It is interesting to note that these adjuncts to treatment of AUD are not prescribed or used as regularly as might be desirable. These drugs are proprietorial, and therefore expensive, and many insurers in the United States do not include them in their formularies. Additionally, evidence supports the bias of some clinicians against use of these drugs, possibly based on a strong belief that the individual alone must be responsible for his or her addiction and recovery (Johnson, Lukens, Kole, & Sisti, 2015). A medication that is sometimes used to help with AUD is disulfiram, commonly known as Antabuse . This drug blocks the normal oxidation of alcohol so that acetaldehyde, a by-product of alcohol, accumulates in the bloodstream and causes unpleas- ant, and at times even life-threatening, symptoms, such as rapid pulse and vomiting. These distressing symptoms serve as a conscious deterrent – an experienced negative reinforcement – to drinking while the person is using Antabuse. However, medication compliance can be difficult with this particular medication, and it is effective only if used as prescribed (Center for Behavioral Health Statistics and Quality, 2020; SAMHSA & NIAAA, 2022). For individuals addicted to opiates, there are a growing number of medication-assisted treatments, including the previously mentioned methadone and different versions of buprenor- phine. Methadone is a synthetic opioid that is commonly used as long-term treatment for opioid addiction, in what is called methadone maintenance . Methadone maintenance includes psychotherapy, psychiatric services, and vocational services to ensure that clients are receiving the care needed to recover from opioid addiction. These programs are not only helpful in allowing individuals to receive the treatment they need because of mitigated withdrawal symptoms; they also decrease other health risks associated with opioid use, including HIV, sexual assault, and other negative consequences. However, because methadone maintenance replaces opioids such as heroin, recovery in this model looks different from recovery in other treatment models. Methadone is also very addictive and discontinuing the drug leads to severe withdrawal symptoms. Support provided in different methadone maintenance pro- grams varies greatly. Therefore, the clinician should carefully consider whether a program is right for a client. Some indi- viduals may benefit from other options, including the use of naltrexone, which prevents individuals from experiencing the effects of narcotics and can be helpful for alcohol dependence as well (Donoghue et al., 2015; SAMHSA & NIAAA, 2022). One of the most effective pharmacologic treatments for opioid use disorders, buprenorphine , also known as “bup,” is a substitu- tion medication for opiate addiction that is less likely to be abused than methadone. It is often paired with naloxone in
the treatment of opioid dependence. Buprenorphine can be prescribed in outpatient settings such as physicians’ offices, which makes it a good option as compared with methadone, which generally requires daily visits to outpatient clinics. Several regulatory measures have been enacted to ensure that physicians do not overprescribe buprenorphine for opioid treatment, including limits on the number of prescriptions per physician (Juman, 2015). Although the federal law is in the process of changing, only physicians are currently permitted to prescribe buprenorphine, and each physician can prescribe the drug to only 100 patients at a time. Nurse practitioners and physician assistants are not allowed to prescribe buprenorphine for opioid dependence, making this the only scenario in which the prescribing of a Schedule III medication is confined to physicians. Even so, the Drug Addiction Treatment Act of 2000 did allow addiction treatment with buprenorphine to move into physicians’ offices, instead of being confined to places like methadone clinics (SAMHSA, 2022; Straussner, 2012). Chemical substitutes are widely used in treatment facilities. However, the long-term effectiveness of these treatments is unclear. It is best to view these treatments as adjuncts to other forms of psychosocial evidence-based interventions.
COMPLEMENTARY AND ALTERNATIVE TREATMENT APPROACHES
There are a number of complementary and alternative (CAM) treatments that are evidence-based methods that result in reductions in substance use. The most widely used and most widely studied CAM for substance use is mindfulness medita- tion that has been combined with relapse prevention, resulting in an evidence-based treatment called mindfulness-based relapse prevention (Bowen et al., 2011). Mindfulness-based approaches have been used effectively to decrease impulsivity and improve emotion regulation (Chiesa & Serretti, 2014). Specifically, mindfulness strategies have been used to help individuals develop and accept awareness of trig- gers and urges to use substances and also to aid in the process of repairing and reversing neuronal changes associated with substance use and relapse (Wittenauer et al., 2015). Yoga, like mindfulness, focuses on interactions between the body and the mind, and on the ways in which physical, emotional, and spiritual factors affect health. Yoga has been employed effectively to help individuals remain in the present moment with focused attention, instead of mentally escaping from the present reality, which is often the case with substance use and abuse. Although studies have suggested that yoga, by reducing stress, can be effective in treating both anxiety and depression, further empirical research is needed (Wittenauer et al., 2015). Another CAM approach is the use of acupuncture, especially as part of an alcohol withdrawal protocol. The use of acupuncture for medical and psychological problems in China and other Eastern societies dates back for centuries. The value of this pro- cedure in the treatment of SUDs requires additional research.
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