Hello everyone and welcome back. In our last sections we have been talking about a variety of aspects related to drug abuse treatment. In this section with begin talking about one specific type of treatment approach. And that is, biological approaches to treatment.

So let's begin by going to slide two. First of all as we can see here, there are a wide variety of approaches. These include detoxification, withdrawal prevention approaches, reinforcement approaches and on, and on, and on. So there is a wide variety of different approaches that one can take. So let's talk a little bit about these approaches.

As we can see in slide three past approaches basically dealt with cold turkey. You wanted the individuals to feel the pain when they stop using so they don't go back to using again. The problem was that there was lots of relapse. Today, what we try to do is reduce the symptoms while the person is coming off the compound which may reduce the immediate medical side effects of withdrawal including seizures and even death.

Now in relation to alcohol withdrawal as we can see in slide four there is a wide variety of substances that can be used. For example, in the past we commonly used Benzodiazepines which was Valium. What we used was a very strict regime which basically reduced it by ten to twenty percent each day. Today, however, we use medications only when the individuals are having a major withdrawal. We use a variety of different medications as well. We still use the Benzodiazepines but we also use other types of drugs as well such as Haloperidol especially when an individual is having some kind of psychotic episode. Often times we begin to use these drugs when the person is experiencing hallucinations or delusions. Some treatment centers also use alcohol on basically a descending curve over two to four days. Again, these are only used in supervised settings.

Now, there is a wide variety of drug treatments that one can use for alcohol dependence. The first of these is shown in slide five. This is called Disulfiram or what is commonly called Antabuse. Antabuse, as we have discussed before interferes with the metabolism of acetaldehyde to acetic acid in the liver. So basically the person avoids drinking alcohol so they do not become nauseated and vomit. This is primarily used in a negative reinforcement model to prevent the person from actually using.

There are a lot of issues that occur and need to be considered when using Antabuse and some of these are shown in slide six. First of all, it should not be used with individuals having serious medical problems such as ulcers or cardiac problems. Antabuse also has a wide variety of side effects such as rashes, neuropathies, and individuals can even die if they consume too much alcohol when using it. Antabuse also does not stop the cravings to drink and that has caused a lot of individuals to not use it as much as they have in the past.

Antabuse as we also see in slide seven takes about twenty-four to forty-eight hours to use after you have taken the medication and is eliminated in about seven to ten days. So basically an individual has to take some Antibuse every day to take effect. And of course if one takes an over the counter cough medications which also contain alcohol the person can have a major reaction. Some centers have used small amounts of alcohol when a client is on Antibuse so the client actually experiences some of the effects. However this is only done under very controlled conditions.

Finally as we can see there is a variety of other side effects which include serotonin level changes, kidney failure, depression, and on, and on, and on. So when one is going to be describing Antabuse or disulfiram for alcoholism one needs to be very considerate of the risks and benefits of the use of the particular drug.

Now there is also, finally, a new phenomenon that is going on out there with individuals taking Antabuse and this is commonly occurring in the younger generation. Basically, what these individuals do is take small amounts of Antabuse and then they drink some alcohol to get a rush-type feeling. This of course causes flushing and assorted other things and that causes some problems as well.

Now, another kind of drug that is used in substance abuse treatment is Lithium. As we see in slide ten, Lithium is basically used in the treatment of Bi-Polar Disorders. It was hypothesized to also work with individuals who are substance abusers, specifically alcoholics. It was hypothesized to reduce relapses and to decrease the level of intoxication. The problem was that it was about as good as a placebo and there was very minimal evidence that it was actually effective for alcoholism. However, from a historical perspective one needs to make sure that one remembers and also understands that alcoholics use Lithium in relation to controlling their Bi-Polar symptoms.

Another major medication that has been used for treatment of both alcoholism and other types of disorders is Naltrexone. Basically, this comes from the point that alcohol causes the release of a variety of endogenous opiates in the system which then causes pleasure. The idea behind the use of Naltrexone was to block these sites, specifically mu receptors, and as a consequence this should reduce the pleasure and consumption should decrease. The result was that the detoxified alcoholics began to experience fewer cravings than placebo subjects.

So what are some of the implications for that? Well, as we can see in slide twelve, the use of Naltrexone decreases pleasure in the reward system so as a result there is less craving and when the person does use the alcohol it makes it less rewarding for people who begin to relapse. This is a newer treatment that has been relatively recently and there has been some success with using it.

Now there is a wide variety of other medications that are used for alcoholism and other types of treatment as well. For example, Flagyl, is a very powerful medication and it causes nausea and vomiting when mixed with alcohol. A variety of Selective Serotonin Reuptake Inhibiters have also been shown to decrease alcohol intake as well, however this area still needs significantly more research as well and will be conducted in the future.

Now in addition to alcohol there is a wide variety of treatments for other drugs as well. So let's talk about opiate treatment for a few minutes. As we can see in slide fourteen, Naltrexone is often used for individuals with opiate treatment and basically works the same way as with alcohol. That is, it blocks the reward centers. This causes the person to stop feeling good after they take the opiates lasting for about seventy-two hours. Often this occurs even before the individual takes the opiates. The problem is that often the cravings return after the naltrexone is discontinued. Basically there is not extinction occurring after stopping the opiate use.

There are some other points as well. Naltrexone should only be taken after the person has detoxified from the drug. Basically often times individuals who are opiate dependent stop taking naltrexone when they are in treatment. As it says here in slide fifteen it is not a magic pill. It works well in the short term with clients who want to stop using but the long term effects are inconclusive. And so consequently when one is using naltrexone with opiate treatment or other disorders one needs to make sure that other treatments are being used as well.

Methadone is also another drug that is used for opiate control and opiate dependence. The rationale for methadone goes something like this. It is basically contended that opiates cause a wide variety of different types of brain damage and that these brain damages occur at the cellular level. If you remove the narcotics from the brain the person begins to experience cravings and these cravings can continue for years. Furthermore, the cravings and removal of the opiates cause the person to feel weird and then as a result of that the cravings and the feeling weird cause the person to start using again. So in essence the person uses the drugs to make the person feel normal. Methadone as an example, seen in slide sixteen, is used to make the person feel normal. And what it does is substitute for the opiate effects. Ultimately, the idea is to decrease the IV narcotic use.

Initially, methadone was part of a larger treatment program for rehabilitation. The problem was, as seen in slide seventeen, is that it did not occur. Many methadone centers basically became drug distribution centers for methadone. The studies are quite clear and they say that when used in combination with other treatment approaches it can be very successful and more cost effective than just methadone alone.

Other studies as we see in slide eighteen also indicate that when used with methadone it reduces other drug related criminal activity. This creates huge cost savings for individuals in society. And it also helps to reduce the spread of HIV.

The problem with all this and the problem with using methadone as we see in slide nineteen is that the permanent damage hypothesis with narcotics has never been proven. So basically, one could take methadone for years and still not see any brain changes.

There is also a wide variety of problems that occur with usage and as we can see in slide twenty, many clients do not just use opiates; they use lots, and lots of compounds. A lot of these drugs actually speed up the metabolism of methadone, including alcohol and cocaine. This causes a wide variety of withdrawal symptoms and cause a lot of drop outs.

In addition, and as seen in slide twenty-one, methadone does not work on all the types of opiate receptors. And, other drugs can cause euphoria even when a person is on methadone. The classic example is Darvon or Darvocet-N.

So in conclusion and seen is slide twenty-two, that while some problems with methadone programs exist, programs are very cost effective. Furthermore, family physicians have recently been authorized to give methadone and this may cause more people to enter treatment. Generally, methadone maintenance can be very effective when used with a combination or variety of rehabilitation packages. However, when used alone its success is somewhat limited.

Now there are other drugs that are used for narcotic treatment and opiate treatment as well. The first of these is shown in slide twenty-three and that is Buprenorphine. What it basically does is block the euphoric effects of narcotics. It has even been proposed as an alternative to methadone. You give it daily like methadone but here it blocks all aspects of the opiate in relation to rewards and euphoria and the withdrawal effects are not as bad as with methadone. In the future we are going to need to develop new protocols and a lot of protocols have been developed to use Buprenorphine very effectively.

Another drug for narcotic treatment is LAMM and basically LAMM prevents withdrawal symptoms. You only need to take it every two to three days which makes it a little bit better than using methadone and the withdrawal is easier.

However, as we can see in slide twenty-five, some individuals will experience withdrawal symptoms regardless of the drug use. This may cause your clients to drop out of the particular program. So consequently you need to let your clients know that hey, you are going to have some symptoms and to be aware of that.

So, how bad really is detoxification? Well, as we can see in slide twenty-six, it depends upon the drugs that are used and the duration that the person has been using the drugs, etc. Detoxification is usually not life threatening especially when done under controlled settings. Generally, for narcotic abuse and even some other types of drug it is usually like having a bad case of the flu. This can be assisted with a variety of other drugs over another four to five day period. Some drugs have even been used that control some symptoms of withdrawal in twenty-four hours or even with the person not experiencing it at all.

However, as we see in slide twenty-seven, detoxification is just the first step. Some people stop forever after they have gone through withdrawal other people need longer therapeutic measures and interventions. However, as we discussed earlier detoxification in combination with a variety of treatment models is very, very good and can be very effective in helping clients overcome addiction. Also, one needs to note, as we see here, that there are a wide variety of other services as well, including social services, employment services, etc.

So we have talked a little bit about opiates and alcohol withdrawal and treatment from a biological perspective, what about cocaine? For cocaine withdrawal and treatment there is a wide variety of drugs that are used and some of these is shown in slide twenty-eight. Some of these drugs are more effective than others while still others do not work at all.

Buprenorphine as we saw with opiate use, even with alcohol has also been shown to be effective at controlling some of the cravings for cocaine. However, it needs more research.

Now there has also been a question that has come up in the research community about whether one even needs to use medications for withdrawal from cocaine. So, Satel et al, as shown in slide thirty looked at the cocaine process. What he found is that the data did not even demonstrate the emergence of severe withdrawal symptoms following the initiation of abstinence from cocaine. There was some craving but it decreased over the first three weeks of recovery. What they concluded was that you do not even need routine pharmacological support for withdrawal from cocaine.

However, one needs to note as we see in slide thirty-one that cocaine is a stimulant and most withdrawals symptoms will be related to lethargy, that is, you are slowing down the nervous system and basically you will experience a lot of recovery in about a week. The cravings are also stimulated through a wide variety of factors as we stated in classical conditioning earlier in the class.

What about some other drugs in relation to pharmacologic treatment? One of these as we see in slide thirty-two is nicotine replacement therapy. This is usually used for nicotine addiction usually provided through cigarettes or chew. As we talked about earlier, nicotine addiction is probably the hardest addiction to kick. The half life for some substances related to cigarette smoking are six months of duration. Nicotine gum, as seen here, gives about one third to two third the amount of nicotine as a cigarette and of course, it can cause a wide variety of side effects.

The results of nicotine replacement therapy, especially with gum, are mixed. As we see in slide thirty-three, the gum can be helpful, but other studies have shown that it has about the same effectiveness as a placebo. It may be beneficial in related to counseling but a lot of the expectations of nicotine replacement therapy are very important. It goes back to a lot of the stuff that we talked about earlier with expectations in related to social learning theories.

Nicotine patches have also been used, and as we see in slide thirty-four, it is basically used to give the person a moderately high level of nicotine. What the idea is is that you are supposed to gradually reduce this level over time. It does reduce the cravings but it does not eliminate everything. They can be very good adjuncts in the treatment process.

The problem is that nicotine patches also have side effects. As we can see in slide thirty-five, you can have toxicity from the nicotine you can get weird dreams, diarrhea, burning sensations, etc. This cause many people to drop out of nicotine replacement therapy programs and start smoking again.

In general as we can see here in slide thirty-six, many individuals relapse even with pharmacologic interventions. The patches also do not deliver the same amount of nicotine as a cigarette or even the gum. And if you are looking to get a drug in about seven seconds the patch does not do well at all.

There have been a wide variety of other treatments used for nicotine and some of these are on slide thirty-seven. These include sprays, silver acetates, etc. Basically, these all have mixed effects.

Buspar, as seen in slide thirty-eight, has also been used and this is related to looking at fatigue and anxiety. What clients report when using this is less fatigue and anxiety and no weight gain in relation to use for nicotine treatment?

In general, as seen in slide thirty-nine, regardless of the approach no single substance has been proven effective to treat nicotine withdrawal beyond any reasonable doubt.

So, what about biological treatments? As we can see in slide forty there is a wide variety of approaches. Most of these are used to control withdrawal symptoms and some are more effective than others. Basically, these substances need to be used in combination with other types of talk-therapies to get the best long term results. The issue here is that there is no magic bullet. There is no magic bullet to stop the addictions process. It is a lot of hard work to get the person over the particular compound that one is taking. In the future there may be some kind of drug that will stop the addictions process but until then we are going to have to use combinations of biological, psychological, and other treatment processes to help us get through the addictions process.

Well that concludes this section. In our next section we are going to talk about psychological treatments related to addictions. So until then we hope you have a good day and we look forward to talking with you again soon.

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