The integration of pharmacological and nonpharmacoiogical treatments for addictive disorders has not extended beyond pharmacological detoxification treatment. Psychiatrists have not taken a leadership position in the diagnosis and treatment of addictive disorders, and have limited their focus of interest to the psychiatric disorders associated with addictive disorders or "dual diagnosis."
The association between the psychiatrist, treatment for addictive disorders, and Alcoholics Anonymous (AA) and other self-help groups remains essentially nonintegrated. Commonly, the psychiatrist restricts his or her practice to psychiatric conditions apart from addiction, despite "psychoactive substance use disorders" having separate status in DSM-IIl-R. The psychiatrist is typically not employed in the primary treatment of addictive disorders, and instead acts as an adjunct to assess "other psychiatric illness" in the addiction treatment populations. Moreover, there is the notion that the psychiatrist can play no role in the long-term recovery from addiction, despite reports that recovering addicts use psychiatric and psychological services and consider them helpful.
Tension is inherent in the respective traditional methods for understanding, diagnosing, and treating psychiatric and addictive disorders. The psychiatric perspective is based on the self-medication hypothesis, which proposes that the addictive use of alcohol and drugs is derived from some underlying psychiatric disorder. The addictive perspective is based on the observations that addiction is an independent disorder that can cause psychiatric symptoms. As currently exercised, the decision to use pharmacological or nonpharmacological therapies in comorbid addictive and psychiatric disorders often will rest on the therapist's perspective and whether the addictive or psychiatric disorder is viewed as independent or contingent on the other disorder.
Another stage for integration is the use of pharmacological agents in conjunction with nonpharmacological treatments in the management of often chronic addictive disorders. Because addictive behavior is characterized by relapse, pharmacological agents are being tested for relapse prevention beyond the withdrawal period. At any stage, however, the progress toward integration will depend on the acceptance of independent status for both categories of disorders - addiction and psychiatric - and knowledge and competence in their diagnosis and treatment.
ADDICTIVE DISORDERS AND PSYCHIATRIC SYNDROMES
Exclusionary Criteria for Substance Use Disorders
Before many Axis 1 diagnoses in DSM-IlI-K can be applied, alcohol and drug use and certain diagnoses must be excluded. These diagnoses are schizophrenia, somatization disorder, cyclothymia, panic disorder, insomnia, hypersomnia, generalized anxiety, obsessive-compulsive disorder, Ton rette's disorder, chronic motor or vocal motor disorder, transient tic disorder, intermittent explosive disorder, and psy chogcnic amnesia. Also, organic factors including specific mention of intoxication and withdrawal from drugs or alcohol are to be excluded for symptoms related to schizophrenia, delusional (paranoid disorder), brief reactive psychosis, schizophreni form disorder, schizoaffeclive disorder, atypical psychosis, manic episodes, dysthymia, psy criogenie fugue, dream anxiety disorder, sleep-terror and sleepwalking disorders, and alcohol-related blackout or cannabis dependence. There are also categories with general exclusions for any Axis 1 disorder.1,2
The evidence is lacking for a self-medication hypothesis as· an etiology or genesis of addictive use of alcohol and drugs. This is an assumption often based on retrospective diagnoses and dogmatic speculation. There are no available objective studies that support the common interpretation that psychiatric disorders are responsible for initiating and sustaining addictive use. Controlled studies show that alcoholics drink despite alcoholinduced depression and that drinking and depression are negatively correlated in nonalcoholics.3'3 Controlled and longitudinal studies show further that anxious or depressed people do not prefer to drink more than nonanxious or !!undepressed people.1,6
While alcoholics report drinking because of anxiety and depression, under laboratory conditions they become increasingly anxious and depressed in a dose-dependent manner as they drink and not before. Similar findings have been reported for cocaine use. The alcoholic/addict rationalizes the consequences to the antecedent position, and self-report by the addict can be a source of confusion to the clinician who takes the alcoholic/addict literally.4,5 The use of defense mechanisms of denial and minimization in other psychopathological states as well as addictive disorders has been well described.
PSYCHIATRIC COMORBIDITY IN ADDICTIVE DISORDERS
Studies employing both pharmacological and nonpharmacological treatments for depression in the setting of addiction have not effectively reduced either the depression or the addiction. Antidepressa n ts, antianxiety agents, and psychotherapy do not relieve the depression and anxiety induced by alcoholism/addiction or the overall course of the addictive use of alcohol and drugs. The same findings hold for other psychiatric disorders in which hallucinations and delusions induced by the addictive use of alcohol and drugs do not respond to conventional psychiatric pharmacological or nonpharmacological therapies.1,2
Studies do confirm that specific treatment of the addictive disorders will alleviate the addictive use of alcohol and drugs and the consequent psychiatric comorbidity. An observation period of days to weeks may be necessary to examine important causal links in the genesis of psychiatric symptoms from addictive disorders and to establish independent psychiatric disorders.1-3
Most psychotropic medications can be used to treat independent psychiatric disorders in alcoholism and drug addiction. Generally beyoncl the detoxifying period in the abstinent state, there is little evidence that patients with addictive disorders respond differently to most psychotropic medications. The caveat is that because of the addiction potential, alcoholics/ addicts are more likely to overuse and lose control of virtually any medications than are the nonaddicted, particularly those medications with already established addictive potential.1
POWER OF MEDICATIONS VS. THE INDIVIDUAL
Physicians are trained to view medications as powerful and inherently good, despite the potential for toxicity. In a situation where prescribing medication may be clinically inappropriate, some psychiatrists may minimize the importance of their role as physicians. Medications may impair cognition and blunt feelings, albeit subtly. Clinicians treating addictive disorders advocate that the alcoholic/addict needs a clear sensorium and access to feelings in order to make fundamental changes. This percept, however, has not been well studied.
The recovering alcohol/drug addict must take an active initiative to change these attitudes and to abandon the long-held belief that alcohol and /or drugs can "treat" life problems and uncomfortable psychological states. When clinically acknowledged, anxiety and depression can provide motivation to change, without which the sufferer has little awareness of the need to change. A commonly used expression to explain this practice among recovering individuals is "no pain, no gain." In other words, symptoms such as anxiety and depression in recovering addicts might be vital to recovery and survival, therefore pharmacotherapy to treat these symptoms must be considered carefully. Enormous misunderstanding lias arisen from a divergence in purpose and perspective toward medications between the physician and the addicted patient, and the lack of knowledge and skill in both.
Roots of the Solution
Psychiatry as a specialty has not yet made the commitment to integrate addictive disorders into the mainstream of clinical practice and education. Very few faculty members in psychiatry departments of medical schools are skilled in the diagnosis and treatment of addictive disorders. Role models for psychiatric resident trainees are sorely lacking in psychiatric departments across the country. Even in those departments where academic leaders in "substance abuse" reside, the orientation is on "psychiatric diagnosis" in addictive disorders and experimental treatments. The standard of care that is used in over 90% of current addiction treatment centers is not openly endorsed by them, namely, abstinence-based 12step programs for the treatment of addictive disorders.6-8
Minimum requirements are needed in psychiatric residency for training in addictive disorders Eo begin preparing trainees in diagnosis and treatment. The "catch 22" of not having role models among faculty can best be broken by training the faculty of tomorrow, now. Minimum requirements will provide the catalyst for psychiatry departments to hire those already trained in addictive disorders as well as encouraging interested faculty members to step forward and to obtain specialized training in order to incorporate addictive disorders in the mainstream of psychiatry.7
Current Standard of Care
The current standard of care for addictive disorders is nonpharmacological beyond the detoxification period. Several studies have shown that treating the addictive disorder with abstinence alone results in improvement in the psychiatric syndromes associated with alcohol and drug use/addiction. Severe depressive and anxiety syndromes induced by alcohol that fulfill criteria for major depression and anxiety disorders in DSM-HI-R resolve within days to weeks with abstinence. Manic syndromes induced by cocaine resolve within hours to days, and schizophrenic syndromes with hallucinations and delusions resolve within days to weeks with abstinence as well.1-3
Further studies are needed to confirm the clinical experience that psychiatric symptoms including anxiety, depression, and personality disorders respond to the specific treatment of addiction. The cognitive behavioral techniques employed in the 12-step treatment approach have been shown to be effective in the management of anxiety and depression associated with addiction.8
Treatment and AA
Available data demonstrate abstinence rates of 6(19;. to 80% after two years for alcohol and other drugs, including cocaine, in both alcoholics and drug addicts in treatment programs based on a 12step approach with referrals to AA. Surveys also show recovery rates of 44% at less than one year, 83%. between one and five years, and 90% at greater than five years attendance at AA (44% of alcoholics in AA are addicted to drugs).11 A recent study revealed that the best treatment outcome is obtained when professional treatment and AA are combined.1" Studies are not yet available that examine the efficacy of psychiatric treatments in enhancing treatment outcome in addicts with psychiatric comorbidity.
The integration of treatment techniques can extend to those patients who have comorbid disorders, and these numbers are growing substantially each year for reasons that are not yet clear. Presently, we do not routinely offer the chronic mentally ill specific treatment of addiction, and instead rely on pharmacological and nonpharmacological psychiatric treatments of these disorders. The overall response to this limited focus of treatment lias been mixed and frustrating for the psychiatrist. Inpatient programs that have incorporated psychiatric and addiction treatments are being developed, but those psychiatrists with the interest and skills are still small in number. The typical approach is to treat the addictive disorder before establishing an independent psychiatric disorder whenever possible. In those instances when the psychiatric disorder requires immediate attention, concurrent treatment of the addictive disorder is required.11,12
Pharmacological Treatments Beyond Withdrawal
Recently, controlled trials have shown that pharmacological agents may have efficacy for subacute withdrawal, or the early months d u ring the initial abs tinence period. These agents have been principally desipramine and carbamazepine for cocaine addiction. Results are tentative and these agents remain experimental awaiting replications and improvements.1-1-14 Antabuse (disulfiram) is a medication with proved efficacy as an adjunct to nonpharmacological treatments for alcoholism.
Agents such as serotonin uptake inhibitors have been studied in social, early, and heavy drinkers and chronic alcoholics. Results show reduction of 10c/i to 26% in number of drinks and in days drinking. Animal studies using these agents have substantiated a decrease in alcohol consumption.13 Naltrexone is another agent that is aimed at reducing alcohol intake by blocking a possible link between alcohol and opiate byproducts from the metabolism of alcohol.
Pharmacological treatments for addictive disorders that suppress the appetitive, instinctual, or motivational drive states in the Iimbic system will likely have the most specific action on addictive disorders. The substrate for reinforcement of drug use utilizes the mesolimbic pathways and interactions with neurotransmitter systems such as serotonin, GABA, and norepinephrine. The development of medications could be aimed at these target structures as primary generators of addictive drug and alcohol use.
INTEGRATION OF PHARMACOLOGICAL AND NONPHARMACOLOGICAL TREATMENTS
The integration of pharmacological and nonpharmacological treatments for addictive disorders and attendant psychiatric comorbidity lies in securing an independent status for each disorder, and utilizing the indicated therapies according to the diagnoses. Although there are relative contraindications for the use of pharmacological agents in patients with addictive disorders, the agents can be used as indicated in these patients with additional psychiatric disorders. A not-well-documented but clinically acknowledged observation is that the treatment of addictive disorders can be difficult without adequate treatment of the psychiatric disorder. For instance, a schizophrenic who is hallucinating and delusional and using alcohol/ drugs cannot enter treatment for addiction without having adequate control over the psychotic symptoms. The same can be true of a manic who is euphoric, delusional, and alcoholic, or of a depressive or phobic who is also addicted to alcohol and/or benzodiazepines.16
Nonpharmacological treatment of a comorbid addictive disorder is indicated for a schizophrenic, manic, depressive, or phobic in order to allow compliance with psychiatric treatments. It is clinically self-evident and supported by data that poor control of the addictive disorder leads to an unfavorable prognosis for the psychiatric disorder. The prognosis of a combined psychiatric and addictive disorder follows that of the addictive disorders, so its treatment is mandatory to affect the course of either disorder.17,18
The overall conclusion based on clinical data and experience is that basic knowledge and adequate clinical skills in both categories of disorders are required before an integration of pharmacological and nonpharmacological treatments can take place. A lack in diagnosis in either category of disorders usually leads to confusion and inadequate treatments for both disorders. In addition, much of the controversy of both pharmacological and nonpharmacological approaches to diagnosis and treatment of psychiatric and addictive disorders can be attributed to the lack of acceptance of an independent status for either disorder.19
The integration of pharmacological agents and nonpharmacological therapies in the long-term management of specific addictive behavior regarding alcohol and drugs awaits further studies. These investigations will require exploration into the biology of addictive behavior beyond the ordinary psychiatric explanations of self-medication as causative for alcohol and drug use.
The following are specific recommendations for achieving an integration of pharmacological and nonpharmacological therapies in the treatment of addictive disorders.
* Accept independent status for addictive and psychiatric disorders.
* Understand the roles of addictive and psychiatric disorders in generating drinking and drug use behavior and psychiatric symptoms.
* Develop minimum requirements in psychiatric residency training programs for addictive disorders.
* Require that psychiatrists develop competency in the diagnosis and treatment of addictive disorders, including both nonpharmacological a nel pharmacological treatments.
* Incorporate into psychiatric knowledge treatment outcome studies for both nonpharmacological and pharmacological treatments for addictive disorders.
* Base the integration of pharmacological and nonpharmacoiogicai treatments on outcome data and not the dogma of disciplines.
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