Substance Abuse Longer Article

Headline A Deeper Understanding of Dependence and Addiction
Kicker Substitutive Therapy? A Drug-Free Environment?
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Substance abuse is the use of illegal substances, the misuse of alcohol or prescribed and over the counter medications. This behavior has many health consequences.  In fact, diseases linked to substance abuse are associated with medical problems that may lead to premature death.  Substance abuse is a medical and psychologic problem and requires a two pronged approach.

People begin using drugs for many reasons. However some are able to avoid dependence while others descend into addiction. The how and why of addiction versus non-addiction this has been the subject of numerous studies but the answer continues to elude us and probably involves both genetic and environmental factors.

Regardless, once someone becomes addicted, many treatment methods are available that can reduce the medical and social problems associated with addiction. The two major treatment options are a drug free environment or substitutive therapy. Both involve counseling to address the psychologic issues that may prevent a patient from becoming abstinent.  If a patient repeatedly fails to maintain abstinence despite adequate counseling, medical therapy may be appropriate and necessary.

Alcohol is the most commonly abused substance and the consequences of abuse are the most severe. These complications include neurologic, liver, lung and lung problems as well as an increased risk of cancer.  The safe level of alcohol consumption for women is one drink daily and no more than three drinks on one occasion. For men, the safe level is no more than two drinks daily or more than three on one occasion. A drink is defined as a twelve ounce beer, five ounce glass of wine or 1.5 ounces of 80 proof spirits. Imbibing greater quantities is considered excessive drinking. A person is dependent upon alcohol if they continue to drink despite problems with work, in relationships, or legal system. If a patient is not at risk for acute withdrawal (DT’s), counseling is the mainstay of treatment. Three medications may be used to increase the success of counseling. Antabuse is used as aversive therapy. If one drinks while taking this medication, they suffer unpleasant flushing. Acamprosate (Campral) and naltexone (Revia, Vivitrol) decrease the pleasant feelings or euphoria associated with drinking.

One theory of addiction is that an alteration of the brain’s receptors sensitivity to endogenous and synthetic neurotransmitters exists and drives a patient to continue drug use. The idea behind substitutive treatment involves stimulating the receptors to ameliorate or abrogate withdrawal symptoms, decrease craving and allow time for counseling to become effective. Currently two medications are approved for substitutive therapy. These include methadone and buprenorphine (Suboxone, Subutex). Both can be used for either long term maintenance or short term tapering of a patient from illicit drugs. Both medications relieve withdrawal symptoms, decrease drug craving and if person should use they decrease the effect of the illicit opiates. Another medical treatment option is Naltrexone which is an opiate antagonist and will block the effects of any ingested opioid. If a person has not used opioids for a period of time (usually four or more days) they may start on Naltrexone. If started sooner, withdrawal may suddenly occur. Therefore this medication is most frequently used after a patient has completed a several week inpatient detoxification. No medication is a magic bullet by itself. Counseling is a necessary and integral part of any type of drug treatment.  Relapse to substance abuse is a part of the disease, however these should become more infrequent as treatment progresses.

Buprenorphine was recently approved for use in drug treatment. Unlike methadone which must be dispensed in a restrictive treatment clinic setting, buprenorphine may be prescribed by a qualified physician in the privacy of their office. Patients dependent on opioids who do not need a highly structured environment find this mode of treatment more acceptable and do well.  Patients who cannot attain and maintain abstinence may need a more structured environment such as an inpatient treatment stay or methadone program.


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