Ebook Principles of addiction medicine the essentials: Part 1

(BQ) Part 1 book Principles of addiction medicine the essentials presents the following contents: Basic science and core concepts, pharmacology, diagnosis, assessment and early intervention, overview of addiction treatment, special issues in addiction medicine, management of intoxication and withdrawal, pharmacologic interventions.

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Library of Congress Cataloging-in-Publication Data

Principles of addiction medicine : the essentials / [edited by] Chris Cavacuiti

p ; cm

ISBN 978-1-60547-776-3

1 Substance abuse—Handbooks, manuals, etc I Cavacuiti, Chris II American Society of

Addiction Medicine

[DNLM: 1 Substance-Related Disorders—therapy—Handbooks 2 Behavior, Addictive—

Handbooks 3 Substance-Related Disorders—diagnosis—Handbooks WM 34]

RC564.15.P75 2010

362.29—dc22

2010031296

Care has been taken to confi rm the accuracy of the information presented and to describe generally

accepted practices However, the authors, editors, and publisher are not responsible for errors or

omissions or for any consequences from application of the information in this book and make no

warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents

of the publication Application of the information in a particular situation remains the professional

responsibility of the practitioner

The authors, editors, and publisher have exerted every effort to ensure that drug selection and

dos-age set forth in this text are in accordance with current recommendations and practice at the time of

publication However, in view of ongoing research, changes in government regulations, and the constant

fl ow of information relating to drug therapy and drug reactions, the reader is urged to check the package

insert for each drug for any change in indications and dosage and for added warnings and precautions

This is particularly important when the recommended agent is a new or infrequently employed drug

Some drugs and medical devices presented in the publication have Food and Drug Administration

(FDA) clearance for limited use in restricted research settings It is the responsibility of the health care

provider to ascertain the FDA status of each drug or device planned for use in their clinical practice

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have been with me every step of the way—

my mother Margaret, my wife Aleksandra, and my daughters Sasha and Emma.

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xiv Editors and Contributors to Principles of Addiction Medicine, 4th Edition

Peter D Friedmann, MD, MPH

Professor, Departments of Medicine & Community

Health

Alpert Medical School of Brown University

Director, Center on Systems, Outcomes & Quality

in Chronic Disease & Rehabilitation

Providence Veterans Affairs Medical Center

Rhode Island Hospital

Providence, Rhode Island

Marc Galanter, MD, FASAM

Professor and Director, Division of Alcoholism and

Drug Abuse

NYU School of Medicine

New York, New York

R Jeffrey Goldsmith, MD

Professor of Clinical Psychiatry

College of Medicine, University of Cincinnati

Staff Psychiatrist

Mental Health Care Line

Cincinnati VA Medical Center

Cincinnati, Ohio

Adam J Gordon, MD, MPH, FACP,

FASAM

Assistant Professor of Medicine and Advisory Dean

University of Pittsburgh School of Medicine

Associate Clinical Director, Mental Illness

Research & Education Center

Center for Health Equity Research and Promotion

VA Pittsburgh Healthcare System

Pittsburgh, Pennsylvania

David A Gorelick, MD, PhD

Intramural Research Program

National Institute on Drug Abuse, National

Institutes of Health

Adjunct Professor, Department of Psychiatry

University of Maryland School of Medicine

Baltimore, Maryland

J Harry Isaacson, MD, FACP

Associate Professor of Medicine

Director of Clinical Education

Cleveland Clinic Lerner College of Medicine

Cleveland Clinic

Cleveland, Ohio

John R Knight, MD

Associate Professor of Pediatrics

Harvard Medical School

Director, Center for Adolescent Substance Abuse

Case Medical CenterUniversity Hospitals of ClevelandCleveland, Ohio

Theodore V Parran, Jr., MD, FACP

Associate Clinical Professor, Department of Internal Medicine

Case Western Reserve University School of MedicineAssociate Medical Director, Rosary Hall Addiction Services

St Vincent Charity HospitalCleveland, Ohio

Richard K Ries, MD, FAPA, FASAM

Professor of PsychiatryDirector, Division of Addictions, Department of Psychiatry and Behavioral Sciences

University of WashingtonMedical Director, Harborview Addictions and Rehabilitation Psychiatry Programs

Harborview Medical CenterSeattle, Washington

Seddon R Savage, MD, MS, FASAM

Director, Dartmouth Center on Addiction Recovery and Education (DCARE)

Pain Consultant, Manchester VA Medical CenterAssociate Professor of Anesthesiology, Dartmouth Medical School, Adjunct Faculty

Hanover, New Hampshire

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Director, The Child and Family Institute

Chief, Division of Child and Adolescent Psychiatry

St Luke’s–Roosevelt Hospital Center

Assistant Professor of Clinical Psychiatry

Columbia University College of Physicians and

Surgeons

New York, New York

Bonnie B Wilford, MS

Executive Director, Coalition on Physician

Education in Substance Use Disorders (COPE)

Senior Principal and Director, Center for Health

Services and Outcomes Research

JBS International, Inc

Easton, Maryland

Joan E Zweben, PhD

Clinical Professor of Psychiatry

University of California, San Francisco

Associate Professor of Medicine

Boston University School of Medicine

Medical Director, MASBIRT and OBOT Programs

Institute of Behavorial MedicineSmyrna, Georgia

Sudie E Back, PhD

Associate Professor, Department of PsychiatryClinical Neuroscience Division, Medical University

of South CarolinaCharleston, South Carolina

Robert L Balster, PhD

Butler Professor of Pharmacology and ToxicologyDirector, Institute for Drug and Alcohol StudiesVirginia Commonwealth University

Richmond, Virginia

Kristen L Barry, PhD

Research Associate ProfessorDepartment of PsychiatryUniversity of MichiganDepartment of Veterans AffairsSerious Mental Illness Treatment Research and Evaluation Center (SMITREC)

Ann Arbor VAMCAnn Arbor, Michigan

Andrea G Barthwell, MD, FASAM

Chief Executive Offi cerTwo Dreams Outer Banks Comprehensive Wellness Center

Corolla, North Carolina

Robert Gordon Batey, MD, FRACP, FRCP (UK), FAChAM

Conjoint Professor of MedicineUniversity of Sydney

Senior Staff Specialist, Addiction MedicineRoyal Prince Alfred Hospital

Camperdown, New South Wales, Australia

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xvi Editors and Contributors to Principles of Addiction Medicine, 4th Edition

Neal L Benowitz, MD

Professor of Medicine, Psychiatry, and

Biopharmaceutical Sciences

Chief, Division of Clinical Pharmacology

San Francisco General Hospital

San Francisco, California

Nicolas Bertholet, MD, MSc

Clinical Epidemiology Center

Institute of Social and Preventive Medicine

Centre Hospitalier Universitaire Vaudois

Alcohol Treatment Center

Department of Community Medicine and Public

Health

Lausanne University, Switzerland

Aurelia N Bizamcer, MD, PhD

Assistant Professor of Psychiatry

Medical Director, Outpatient Psychiatry

Temple University School of Medicine

Philadelphia, Pennsylvania

Anton C Bizzell, MD

Vice President, Health and Clinical Services

DB Consulting Group, Inc

Silver Spring, Maryland

Clinical Instructor, Community Health and Family

Practice

Howard University Hospital

Washington, District of Columbia

Richard D Blondell, MD

Professor of Family Medicine

University at Buffalo

Attending Physician

Erie County Medical Center

Buffalo, New York

Frederic C Blow, PhD

Department of Psychiatry

University of Michigan

Department of Veterans Affairs

Serious Mental Illness Treatment Research and

Evaluation Center (SMITREC)

Ann Arbor VAMC

Ann Arbor, Michigan

Lisa Borg, MD

Senior Research Associate, The Laboratory of the

Biology of Addictive Diseases

The Rockefeller University

Associate Attending Physician

The Rockefeller University Hospital

New York, New York

Gilbert J Botvin, PhD

Professor of Public Health and PsychiatryWeill Cornell Medical Center

Attending PsychologistDepartment of PsychiatryThe New York Presbyterian HospitalNew York, New York

Andria Botzet, MA

Research Program CoordinatorDepartment of PsychiatryUniversity of MinnesotaMinneapolis, Minnesota

Carol J Boyd, PhD, MSN, RN, FAAN

Professor of NursingDirector, Institute for Research on Women and GenderUniversity of Michigan

Ann Arbor, Michigan

Katharine A Bradley, MD, MPH

Associate Professor of MedicineUniversity of WashingtonGeneral Internist

VA Primary and Medical Care Services, Division of General Internal Medicine

VA Puget Sound & University of WashingtonSeattle, Washington

Kathleen T Brady, MD, PhD

Professor of PsychiatryMedical University of South CarolinaCharleston, South Carolina

Lawrence S Brown, Jr., MD, MPH, FASAM

Clinical Associate Professor of Public HealthWeill Medical College, Cornell UniversityExecutive Senior Vice President

Medical Services, Research & Information Technology

Addiction Research & Treatment CorporationNew York, New York

Richard A Brown, PhD

Professor of Psychiatry and Human BehaviorWarren Alpert Medical School at Brown University

Director of Addictions ResearchButler Hospital

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John C.M Brust, MD

Professor, Department of Neurology

Columbia University

Director of Neurology

Harlem Hospital Center

New York, New York

Professor of Family Medicine

Case Western Reserve University

Chairman, Family Medicine/Geriatrics

Metro Health

Cleveland, Ohio

Victor A Capoccia, PhD

Senior Scientist

Center for Health Enhancement System Studies

Network for the Improvement of Addiction

Treatment

University of Wisconsin

Madison, Wisconsin

Kathleen M Carroll, PhD

Professor, Department of Psychiatry

Yale University School of Medicine

New Haven, Connecticut

Domenic A Ciraulo, MD

Professor and Chairman, Department of Psychiatry

Director, Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services

Administration

Department of Health and Human Services

Rockville, Maryland

Jeffrey S Cluver, MD

Associate Professor of Psychiatry

Medical University of South Carolina

Assistant Chief, Mental Health Service

Ralph H Johnson VAMC

Charleston, South Carolina

Peggy Compton, RN, PhD, FAAN

Professor, School of NursingUniversity of California, Los AngelesLos Angeles, California

Katherine Anne Comtois, PhD, MPH

Associate Professor, Department of Psychiatry and Behavioral Sciences

University of WashingtonClinical Director, Dialectical Behavior Therapy Program

Harborview Mental Health ServicesHarborview Medical CenterSeattle, Washington

Edward C Covington, MD

Director, Neurological Center for PainCleveland Clinic FoundationCleveland, Ohio

Rosa M Crum, MD, MHS

ProfessorDepartment of Epidemiology, Psychiatry and Mental Health

Welch Center for Prevention, Epidemiology &

Clinical ResearchJohns Hopkins Medical InstitutionsBaltimore, Maryland

Dennis C Daley, PhD

Professor of PsychiatryUniversity of PittsburghChief, Addiction Medicine ServicesWestern Psychiatric Institute and ClinicPittsburgh, Pennsylvania

John A Dani, PhD

Professor of NeuroscienceBaylor College of MedicineHouston, Texas

Itai Danovitch, MD

Director, Addiction Psychiatry Clinical ServicesAssociate Director, Addiction Psychiatry FellowshipDepartment of Psychiatry and Behavioral Neurosciences

Cedars-Sinai Medical CenterLos Angeles, California

Jose Carlos T DaSilva, MD, MPH

Assistant Clinical Professor, Department of Medicine

Boston University School of MedicineStaff Physician, Commonwealth Nephrology Association

Boston, Massachusetts

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xviii Editors and Contributors to Principles of Addiction Medicine, 4th Edition

William E Dickinson, DO, FASAM,

Chief Scientifi c Offi cer

Behavioral Tech Research, Inc

Seattle, Washington

Carson V Dobrin, BS

Graduate Student

Neuroscience Program

Wake Forest University School of Medicine

Winston-Salem, North Carolina

Chief, Department of Adult Emergency Services

Yale-New Haven Hospital

Antoine Douaihy, MD

University of Pittsburgh School of Medicine

Medical Director, Addiction Medicine Services

Director of Addiction Psychiatry Fellowship

Western Psychiatric Institute and Clinic

Pittsburgh, Pennsylvania

Robert L DuPont, MD, FASAM

Clinical Professor of Psychiatry

Tamara Fahnhorst, MPH

Research Program CoordinatorDepartment of PsychiatryUniversity of MinnesotaMinneapolis, Minnesota

Kathleen J Farkas, PhD, LISW-S, ACSW

Associate ProfessorMandel School of Applied Social SciencesCase Western Reserve UniversityCleveland, Ohio

Sergi Ferré, MD, PhD

Principal InvestigatorBehavioral Neuroscience BranchNational Institute on Drug AbuseBaltimore, Maryland

David A Fiellin, MD

Professor of MedicineDepartment of Internal MedicineYale University School of MedicineNew Haven, Connecticut

John W Finney, PhD

HSR&D Center for Health Care Evaluation

VA Palo Alto Health Care SystemPalo Alto, California

Stanford University School of MedicineMenlo Park, California

Marc Fishman, MD

Assistant Professor of PsychiatryJohns Hopkins UniversityMedical DirectorMountain Manor Treatment CenterBaltimore, Maryland

Michael F Fleming, MD, MPH

Professor of Family MedicineNorthwestern University Feinberg School of Medicine

Chicago, Illinois

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Keith Flower, MD

Scientist

Addiction Pharmacology Research Lab

California Pacifi c Medical Center Research Institute

St Luke’s Hospital

P Joseph Frawley, MD

Co-Medical Director, Intensive Outpatient Program

Recovery Road Medical Center

Assistant Medical Director

Cottage Residential Treatment Center

Santa Barbara Cottage Hospital

Santa Barbara, California

Howard S Friedman, MD

Clinical Professor of Cardiology

New York University School of Medicine

New York, New York

Peter D Friedmann, MD, MPH

Professor, Departments of Medicine & Community

Health

Alpert Medical School of Brown University

Director, Center on Systems, Outcomes & Quality in

Chronic Disease & Rehabilitation

Providence Veterans Affairs Medical Center Rhode

Island Hospital

Marc Galanter, MD, FASAM

Professor and Director

Division of Alcoholism & Drug Abuse

NYU School of Medicine

New York, New York

Rollin M Gallagher, MD, MPH

Deputy National Program Director for Pain

Management

Veterans Health System

Director for Pain Policy Research and Primary Care

Penn Pain Medicine

Clinical Professor of Psychiatry and Anesthesiology

Gantt P Galloway, PharmD

Scientist, Addiction Pharmacology Research Laboratory

California Pacifi c Medical Center Research Institute

Linn Goldberg, MD, FACSM

Professor and Head, Division of Health Promotion and Sports Medicine

Oregon Health & Science UniversityPortland, Oregon

Bruce A Goldberger, PhD, DABFT

Professor and Director of ToxicologyDepartments of Pathology, Immunology &

Laboratory Medicine, and PsychiatryUniversity of Florida College of MedicineGainesville, Florida

R Jeffrey Goldsmith, MD

Professor of Clinical PsychiatryCollege of Medicine, University of CincinnatiStaff Psychiatrist

Mental Health Care LineCincinnati VA Medical CenterCincinnati, Ohio

David A Gorelick, MD, PhD

Intramural Research ProgramNational Institute on Drug AbuseNational Institutes of HealthAdjunct Professor

Department of PsychiatryUniversity of Maryland School of MedicineBaltimore, Maryland

Jon E Grant, MD, JD, MPH

Professor, Department of PsychiatryUniversity of Minnesota Medical SchoolMinneapolis, Minnesota

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xx Editors and Contributors to Principles of Addiction Medicine, 4th Edition

Kenneth W Griffi n, PhD, MPH

Associate Professor of Public Health

Weill Cornell Medical College

New York, New York

Senior Research Scientist

Prevention Research Center

Pacifi c Institute for Research and Evaluation

Berkeley, California

Nady el-Guebaly, MD

Professor and Head, Addiction Division

University of Calgary

Consultant, Addictions Program

Alberta Health Services

Paul S Haber, MD, FRACP, FAChAM

Head, Discipline of Addiction Medicine

University of Sydney

Director, Drug Health Services

Royal Prince Alfred Hospital

Camperdown, New South Wales, Australia

Karen J Hartwell, MD

Associate Professor, Department of Internal Medicine

College of Medicine, Mayo Clinic

Associate Director, Nicotine Dependence Center

Mayo Clinic

Rochester, Minnesota

Derya Bora Hazar, MD

Assistant Clinical Professor of MedicineTufts University School of MedicineSection Chief of NephrologyCarney Hospital

Hon Peggy Fulton Hora, JD

Judge of the Superior Court of California (Retired)

Nicotine Dependence CenterMayo Clinic

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Alain Joffe, MD, MPH

Johns Hopkins University School of Medicine

Johns Hopkins Hospital

Professor (Research) of Community Health

Center for Alcohol and Addiction Studies

Brown University

Lori D Karan, MD, FACP, FASAM

Associate Clinical Professor of Medicine

Jason R Kilmer, PhD

Research Assistant Professor, Psychiatry and

Behavioral Sciences

Assistant Director of Health and Wellness for

Alcohol and Other Drug Education

Division of Student Life

University of Washington

Seattle, Washington

Clifford M Knapp, PhD

Associate Professor, Department of Psychiatry

John R Knight, MD

Director, Center for Adolescent Substance Abuse

Case Medical CenterUniversity Hospitals of ClevelandCleveland, Ohio

Henry R Kranzler, MD

Treatment Research CenterUniversity of PennsylvaniaPhiladelphia, Pennsylvania

Igor Kravets, MD

Instructor of Clinical InvestigationLaboratory of Addictive DiseasesThe Rockefeller UniversityAssociate Attending PhysicianThe Rockefeller University HospitalNew York, New York

Mary Jeanne Kreek, MD

Professor and Head, Laboratory of the Biology of Addictive Diseases

The Rockefeller University; Senior PhysicianRockefeller University Hospital

New York, New York

Donald J Kurth, MD, MBA, MPA, FASAM

Associate Professor, Departments of Psychiatry and Preventive Medicine

Loma Linda UniversityChief of Addiction Medicine, Psychiatry DepartmentLoma Linda University Behavioral Medicine CenterRedlands, California

Maritza Lagos-Saez, MD, DABAM

Assistant Professor and Director of Medical Student Education

Department of PsychiatryMichigan State University College of Human MedicineKalamazoo Center for Medical Studies

Attending Physician, Borgess Medical CenterKalamazoo, Michigan

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xxii Editors and Contributors to Principles of Addiction Medicine, 4th Edition

David Y-W Lee, PhD

Director, Bio-Organic and Natural Products Lab

McLean Hospital

Elizabeth Mirabile Levens, MD

Waterbury Pulmonary Associates

Waterbury, Connecticut

Adam M Leventhal, PhD

Assistant Professor of Preventive Medicine and

Psychology

University of Southern California

Division of Health Behavior Research

USC Keck School of Medicine

Los Angeles, California

Assistant Professor of Pediatrics

Medical Director, Adolescent Substance

Medical DirectorJim Gilmore Jr Community Healing CenterKalamazoo, Michigan

Marsha M Linehan, PhD

Professor, Department of PsychologyDirector, Behavioral Research & Therapy Clinics (BRTC)

University of WashingtonSeattle, Washington

Scott E Lukas, PhD

Professor of Psychiatry and PharmacologyHarvard Medical School

Boston, MassachusettsDirector, Neuroimaging CenterDirector, Behavioral Psychopharmacology Research Laboratory

McLean HospitalBelmont, Massachusetts

Alan Ona Malabanan, MD, FACE

Assistant Professor of MedicineHarvard Medical SchoolAttending PhysicianEndocrinology, Diabetes and MetabolismBeth Israel Deaconess Medical CenterBoston, Massachusetts

Issam A Mardini, MD, PhD

Assistant Professor, Departments of Anesthesiology and Critical Care

University of PennsylvaniaAttending, Penn Pain Medicine Center and Department of Anesthesiology

University of Pennsylvania Health SystemPhiladelphia, Pennsylvania

John J Mariani, MD

Assistant Professor of Clinical PsychiatryColumbia University

Psychiatrist IINew York State Psychiatric Institute, Division on Substance Abuse

New York, New York

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BAART Turk Street Clinic

W Alex Mason, PhD

Research Associate Professor

Social Development Research Group

School of Social Work

Seattle, Washington

Martha A Maurer, MSW, MPH, PhD

Assistant Researcher

Pain & Policy Studies Group

University of Wisconsin School of Medicine and

Dennis McCarty, PhD

Professor

Department of Public Health & Preventive Medicine

Oregon Health & Science University

Portland, Oregon

Richard A McCormick, PhD

Senior Scholar

Center for Health Care Research and Policy

Case Western Reserve University

Cleveland, Ohio

Barbara S McCrady, PhD

Distinguished Professor of Psychology

Director, Center on Alcoholism, Substance Abuse

and Addictions (CASAA)

University of New Mexico

Albuquerque, New Mexico

James R McKay, PhD

Professor of PsychiatryUniversity of PennsylvaniaDirector, Center of Excellence in Substance Abuse Treatment and Education

VA Medical CenterPhiladelphia, Pennsylvania

A Thomas McLellan, PhD

Director, Penn Center for Substance Abuse Solutions

Professor of PsychiatryUniversity of Pennsylvania School of MedicinePhiladelphia, Pennsylvania

Mary G McMasters, MD

Assistant Professor of Addiction Medicine and General Internal Medicine

University of VirginiaCo-Medical DirectorPantops Clinic (MMT)Charlottesville, Virginia

David Mee-Lee, MD

ConsultantDML Training and ConsultingDavis, California

Lisa J Merlo, PhD, MPE

Assistant ProfessorDepartment of PsychiatryUniversity of FloridaDirector of ResearchProfessionals Resource Network, Inc

Gainesville, Florida

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xxiv Editors and Contributors to Principles of Addiction Medicine, 4th Edition

Shannon C Miller, MD, FASAM, FAPA,

CMRO

Medical Director, Integrated Dual Diagnosis and

Sobriety Plus Clinics

Program Director, VA Advanced Fellowship in

Addiction Research/Medicine

Cincinnati VA Medical Center

Associate Director of Education, Training, and

Dissemination

Center of Excellence for Treatment, Research, and

Education in Addictive Disorders (CeTREAD)

Addiction Sciences Division

Associate Professor of Clinical Psychiatry, Affi liated

Department of Psychiatry and Behavioral Neuroscience

University of Cincinnati School of Medicine

Cincinnati, Ohio

Rudolf H Moos, PhD

Professor Emeritus, Department of Psychiatry and

Behavioral Sciences

Stanford University School of Medicine

Health Research Science Specialist, Research Service

Department of Veterans Affairs Health

Care System

Palo Alto, California

Hugh Myrick, MD

Director, Mental Health Service Line

Eric J Nestler, MD, PhD

Nash Family Professor and Chair

Department of Neuroscience

Mount Sinai School of Medicine

New York, New York

Edward V Nunes, MD

Professor of Clinical Psychiatry

Surgeons

New York State Psychiatric Institute

Associate Attending Psychiatrist

New York Presbyterian Hospital

New York, New York

Patrick G O’Connor, MD, MPH

Professor of Medicine

Chief, Section of General Internal Medicine

Yale-New Haven Hospital

Brian L Odlaug, BA

Research Associate, Department of PsychiatryGraduate Student, School of Public HealthUniversity of Minnesota

Minneapolis, Minnesota

James A.D Otis, MD

Associate ProfessorDepartment of NeurologyBoston University School of MedicineDirector, Pain Management GroupBoston Medical Center

Theodore V Parran, Jr., MD, FACP

Associate Clinical Professor, Department of Internal Medicine

Case Western Reserve University School of Medicine

Associate Medical Director, Rosary Hall Addiction Services

St Vincent Charity HospitalCleveland, Ohio

J Thomas Payte, MD

Medical DirectorDrug Dependence AssociatesSan Antonio, Texas

Michael Perloff, MD

Resident, Department of NeurologyBoston University, Boston Medical CenterBoston, Massachusetts

Karran A Phillips, MD, MSc

Staff ClinicianIntramural Research ProgramNational Institute on Drug AbuseNational Institutes of HealthAdjunct Assistant ProfessorDivision of General Internal MedicineJohns Hopkins School of MedicineBaltimore, Maryland

Marc N Potenza, MD, PhD

Associate ProfessorDepartment of Psychiatry and Child StudyYale School of Medicine

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Vladimir Poznyak, MD, PhD

Coordinator, Management of Substance Abuse

Department of Mental Health and Substance Abuse

World Health Organization (WHO)

Geneva, Switzerland

James O Prochaska, PhD

Professor and Director, Cancer Prevention Research

Center

University of Rhode Island

Kingston, Rhode Island

Terri L Randall, MD

Instructor, Department of Psychiatry and Human

Behavior

Division of Child and Adolescent Psychiatry

Assistant Director, Child and Adolescent Psychiatry

Fellowship Program

Thomas Jefferson University

Philadelphia, Pennsylvania

Lillian G Remer, MA

Associate Research Scientist

Pacifi c Institute for Research & Evaluation

Richard K Ries, MD, FAPA, FASAM

Professor of Psychiatry

Director, Division of Addictions, Department of

Psychiatry and Behavioral Sciences

Medical Director, Harborview Addictions and

Rehabilitation Psychiatry Programs

Harborview Medical Center

Seattle, Washington

David C.S Roberts, PhD

Professor

Department of Physiology and Pharmacology

Wake Forest University School of Medicine

Winston-Salem, North Carolina

Randall E Rogers, PhD

Addictions Treatment Program Director

Harry S Truman Memorial Veterans Hospital

Columbia, Missouri

Richard N Rosenthal, MD

Antenucci Professor of Clinical Psychiatry and

Senior Associate Dean

Surgeons

Chairman, Department of Psychiatry and

Behavioral Health

St Luke’s–Roosevelt Hospital Center

New York, New York

Bruce J Rounsaville, MD

Professor of PsychiatryYale University School of MedicineDirector, New England Mental Illness Research and Education Center

VA Connecticut HealthcareNew Haven, Connecticut

Stanley Sacks, PhD

Director, Center for the Integration of Research &

PracticeNational Development & Research Institutes, Inc

New York, New York

Richard Saitz, MD, MPH, FACP, FASAM

Professor of Medicine and EpidemiologyDirector, Clinical Addiction Research and Education (CARE) Unit

Section of General Internal Medicine, Department

of MedicineBoston Medical Center/Boston University Schools

of Medicine and Public HealthBoston, Massachusetts

Michael E Saladin, PhD

Associate ProfessorDepartment of Health Sciences and Research and Department of Psychiatry and Behavioral SciencesClinical Neuroscience Division

Medical University of South CarolinaCharleston, South Carolina

Jeffrey H Samet, MD, MA, MPH

Professor of Medicine and Community Health Sciences

Boston University Schools of Medicine and Public Health

Chief, General Internal MedicineBoston Medical Center

Jussi J Saukkonen, MD

Associate Professor of MedicineDepartment of Pulmonary and Critical Care Medicine

Boston University School of MedicineBoston, Massachusetts

Seddon R Savage, MD, MS, FASAM

Director, Dartmouth Center on Addiction Recovery and Education (DCARE)

Pain Consultant, Manchester VA Medical CenterAssociate Professor of Anesthesiology, Dartmouth Medical School, Adjunct Faculty

Hanover, New Hampshire

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xxvi Editors and Contributors to Principles of Addiction Medicine, 4th Edition

Andrew J Saxon, MD

Professor of Psychiatry and Behavioral Sciences

Director, Addiction Patient Care Line

Mental Health Service

VA Puget Sound Health Care System

Seattle, Washington

Hon William G Schma, (Ret)

Kalamazoo Circuit Court

Chief Resident Department of Internal Medicine

University of South Florida

Attending/Chief Resident

James A Haley VA Hospital

Tampa, Florida

Steven J Shoptaw, PhD

Professor, Department of Family Medicine

University of California, Los Angeles

Los Angeles, California

Gerald D Shulman, MA, MAC,

Program Director, Psychiatry

Section Head, Division of Child and Adolescent

Psychiatry

Residency Training Director

Adjunct Associate Professor

University of South Alabama Medical School

Mobile, Alabama

David A Smelson, PsyD

Professor/Vice Chair of Clinical Research

St Luke’s–Roosevelt Hospital CenterAssistant Professor of Clinical PsychiatryColumbia University College of Physicians and Surgeons

New York, New York

Crystal R Spotts, MEd

Senior Research PrincipalDepartment of PsychiatryUniversity of Pittsburgh Medical CenterWestern Psychiatric Institute and ClinicPittsburgh, Pennsylvania

Marc L Steinberg, PhD

Assistant Professor of PsychiatryRobert Wood Johnson Medical SchoolNew Brunswick, New Jersey

Randy Stinchfi eld, PhD

Associate DirectorCenter for Adolescent Substance Abuse ResearchDepartment of Psychiatry

University of MinnesotaMinneapolis, Minnesota

Detroit, Michigan

Amanda M Stone, BS

Medical StudentUniversity of FloridaGainesville, Florida

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Columbia College of Physicians and Surgeons

New York State Psychiatric Institute

New York, New York

Zebulon Taintor, MD

New York University School of Medicine

Consulting Attending Psychiatrist

Bellevue Hospital

New York, New York

Jeanette M Tetrault, MD

Assistant Professor of Medicine

Department of Internal Medicine

Juana Maria Tomás-Rosselló, MD, MPH

Treatnet Coordinator, Southeast Asia

Regional Centre for East Asia and the Pacifi c

United Nations Offi ce on Drugs and Crime

Vienna, Austria

J Scott Tonigan, PhD

Research Professor, Department of Psychology

Center on Alcoholism, Substance Abuse, and

Addictions (CASAA)

University of New Mexico

Albuquerque, New Mexico

Andrew J Treno, PhD

Research Scientist

Pacifi c Institute for Research and Evaluation

Himanshu P Upadhyaya, MD, MBBS, MS

Associate Professor, Department of Psychiatry and

Behavioral Sciences

Adrienne D Vaiana, BS

Research Coordinator IIDepartment of PsychiatryUniversity of Massachusetts Medical SchoolWorcester, Massachusetts

Nora D Volkow, MD

DirectorNational Institute on Drug AbuseChief

Laboratory of NeuroimagingNational Institute on Alcohol Abuse and AlcoholismBethesda, Maryland

Angela E Waldrop, PhD

Assistant ProfessorDepartment of PsychiatryUniversity of California, San FranciscoStaff Psychologist, PTSD Clinical TeamSan Francisco VA Medical CenterSan Francisco, California

Hong Wang, MD, PhD

Instructor of PsychiatryHarvard Medical SchoolBio-Organic and Natural Products LabMcLean Hospital

Belmont, Massachusetts

Elizabeth A Warner, MD

Associate Professor of Internal MedicineUniversity of South Florida College of MedicineMedical Director, Ambulatory ServicesTampa General Hospital

Tampa, Florida

Michael F Weaver, MD, FASAM

Associate Professor of Internal Medicine and Psychiatry

Virginia Commonwealth UniversityMedical Director, Substance Abuse Consult Service

Medical College of Virginia HospitalRichmond, Virginia

Melissa Weddle, MD, MPH

Associate Professor of PediatricsDoernbecher Children’s HospitalOregon Health and Science UniversityPortland, Oregon

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xxviii Editors and Contributors to Principles of Addiction Medicine, 4th Edition

Department of Pharmacology and Toxicology

Virginia Commonwealth University

Richmond, Virginia

Joseph J Westermeyer, MD, MPH, PhD

University of Minnesota

Medical Director, Addictive Disorders Service

Minneapolis VA Medical Center

Minneapolis, Minnesota

David B Wexler, JD

Professor of Law

University of Puerto Rico

San Juan, Puerto Rico

Addiction Treatment Service

VA Palo Alto Health Care System

Palo Alto, California

Bonnie B Wilford, MS

Executive Director, Coalition on Physician

Education in Substance Use Disorders (COPE)

Senior Principal and Director, Center for Health

Services and Outcomes Research

Cedars-Sinai Medical CenterLos Angeles, California

Vern Williams, MD

Medical DirectorHazelden SpringbrookNewberg, Oregon

Kevin C Wilson, MD

Assistant Professor of MedicineBoston University School of MedicineAttending Physician, Pulmonary, Critical Care, and Allergy

Boston Medical CenterBoston, Massachusetts

Bruce J Winick, JD

Professor of Law, School of LawProfessor of Psychiatry and Behavioral SciencesUniversity of Miami

Coral Gables, Florida

Ken C Winters, PhD

Professor of PsychiatryUniversity of Minnesota Medical SchoolMinneapolis, Minnesota

Alex Wodak, AM, MB BS, FRACP, FAChAM

Director, Alcohol and Drug Service

St Vincent’s HospitalSydney, New South Wales, Australia

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John J Woodward, PhD

Professor, Department of Neurosciences,

Department of Psychiatry and Behavioral Sciences

Center for Drug and Alcohol Programs

Tara M Wright, MD

Staff Psychiatrist, Medical Health Service Line

Martha J Wunsch, MD, FAAP, FASAM

Sarah W Yip, BA, MSc

PhD Student, Department of Psychiatry

Anne Zajicek, MD, PharmD

Pediatric Medical Offi cer, Associate Branch ChiefObstetric and Pediatric Pharmacology BranchCenter for Research for Mothers and ChildrenEunice Kennedy Shriver National Institute of Child Health and Human Development

National Institutes of HealthBethesda, Maryland

Aleksandra Zgierska, MD, PhD

Assistant ProfessorDepartment of Family MedicineUniversity of Wisconsin Hospital and Clinics Center for Addictive Disorders

University of Wisconsin School of Medicine and Public Health

Madison, Wisconsin

Douglas M Ziedonis, MD, MPH

Professor and Chairman, Department of PsychiatryUMass Memorial Health Care and University of Massachusetts Medical School

Worcester, Massachusetts

Joan E Zweben, PhD

Clinical Professor of PsychiatryUniversity of California, San FranciscoExecutive Director

East Bay Community Recovery ProjectOakland, California

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xxxii Contents

21 Environmental Approaches to

Prevention 97

Andrew J Treno, Paul J Gruenewald,

Harold D Holder, and Lillian G Remer

Section 4.

Overview of Addiction Treatment

22 Addiction Medicine in America: Its

Birth and Early History (1750–1935)

with a Modern Postscript 101

William L White

23 Treatment of Heavy Drinking and

Alcohol Use Disorders 105

Mark J Willenbring

24 The Treatment of Drug Addiction:

An Overview 110

Andrea G Barthwell and Lawrence S Brown, Jr

25 Integrating Evidence-Based Components

into a Functional Continuum of

Addiction Care 118

A Thomas McLellan and James R McKay

26 Effects of Treatment Setting, Duration,

and Amount on Patient Outcomes 124

John W Finney, Rudolf H Moos,

and Paula L Wilbourne

27 The ASAM Placement Criteria and

Matching Patients to Treatment 127

David Mee-Lee and Gerald D Shulman

28 Linking Addiction Treatment with

Other Medical and Psychiatric

Treatment Systems 137

Peter D Friedmann, Karran A Phillips,

Richard Saitz, and Jeffrey H Samet

29 Alternative Therapies for Alcohol and

Drug Addiction 142

David Y-W Lee and Hong Wang

30 The Harm Reduction Approach to

Prevention and Treatment 144

Alex Wodak

31 Quality Improvement for Addiction

Juana Maria Tomás-Rosselló

Section 5.

Special Issues in Addiction Medicine

33 Nonmedical Use of Prescription Medications 157Martha J Wunsch, Carol Boyd,

and Mary G McMasters

34 Special Issues in Treatment: Women 162Joan E Zweben

35 Treatment of Older Adults 167Fred C Blow and Kristin L Barry

36 Cultural Issues in Addiction Medicine 173Joseph J Westermeyer

37 College Student Drinking 177Mary E Larimer, Jason R Kilmer,

and Ursula Whiteside

38 Pathologic Gambling: Clinical Characteristics and Treatment 181Jon E Grant, Brian L Odlaug, and Marc N Potenza

39 Sexual Addiction 185Steven J Shoptaw

40 Physician Health Programs and Addiction Among Physicians 190Paul H Earley

42 Management of Alcohol Intoxication and Withdrawal 204Michael F Mayo-Smith

43 Management of Sedative-Hypnotic Intoxication and Withdrawal 212William E Dickinson and Steven J Eickelberg

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44 Management of Opioid Intoxication

and Withdrawal 223Jeanette M Tetrault and Patrick G O’Connor

45 Management of Stimulant,

Hallucinogen, Marijuana, Phencyclidine, and Club Drug Intoxication and Withdrawal 229Jeffery N Wilkins, Itai Danovitch,

and David A Gorelick

Section 7.

Pharmacologic Interventions

46 Medications for Use in Alcohol

Rehabilitation 245Henry R Kranzler, Domenic A Ciraulo, and Jerome H Jaffe

47 Pharmacologic Interventions for

Sedative-Hypnotic Addiction 251Jeffrey S Cluver, Tara M Wright, and

Hugh Myrick

Opioid Dependence 254Susan M Stine and Thomas R Kosten

49 Opioid Maintenance Treatment 260

Judith Martin, Joan E Zweben, and J Thomas Payte

50 Special Issues in Office-Based Opioid

Treatment 268Andrew J Saxon

Cocaine, Methamphetamine, and Other Stimulant Addiction 272David A Gorelick

Tobacco Dependence 278Richard D Hurt, Jon O Ebbert,

and J Taylor Hays

Other Drug and Multiple Drug Addiction 284Jeffery N Wilkins, Mark Hrymoc,

and David A Gorelick

56 Individual Psychotherapy 300Bruce J Rounsaville, Kathleen M Carroll,

and Sudie E Back

57 Contingency Management and the Community Reinforcement Approach 305Stephen T Higgins, Jennifer W Tidey,

and Randall E Rogers

58 Behavioral Interventions in Smoking Cessation 311Christopher W Kahler, Adam M Leventhal, and Richard A Brown

59 Network Therapy 317Marc Galanter

60 Therapeutic Communities 321Donald J Kurth

61 Aversion Therapies 325

P Joseph Frawley and Matthew O Howard

62 Family Involvement in Addiction, Treatment, and Recovery 330Michael R Liepman, Theodore V Parran, Jr., Kathleen J Farkas, and Maritza Lagos-Saez

63 Twelve-Step Facilitation Approaches 335Kathleen M Carroll

64 Microprocessor Abuse and Internet Addiction 337Zebulon Taintor and Richard N Rosenthal

65 Relapse Prevention: Clinical Models and Intervention Strategies 340Antoine Douaihy, Dennis C Daley, G Alan Marlatt, and Crystal E Spotts

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xxxiv Contents

66 Integrating Pharmacological and

Behavioral Treatments 345

Richard N Rosenthal and Richard K Ries

Section 9.

Mutual Help, Twelve-Step, and Other

Recovery Programs

67 Twelve-Step Programs in Recovery 349

Jerome E Schulz, Vern Williams, and

Barbara S McCrady and J Scott Tonigan

72 Liver Disorders Related to Alcohol

and Other Drug Use 388

Paul S Haber and Robert Gordon Batey

73 Renal and Metabolic Disorders Related

to Alcohol and Other Drug Use 399

Jose Carlos T DaSilva and Derya Bora Hazar

74 Gastrointestinal Disorders Related to

Alcohol and Other Drug Use 405

Paul S Haber

75 Respiratory Tract Disorders Related

to Alcohol and Other Drug Use 411

Kevin C Wilson, Elizabeth Mirabile Levins,

and Jussi J Saukkonen

76 Neurologic Disorders Related to Alcohol and Other Drug Use 420John C.M Brust

77 HIV, TB, and Other Infectious Diseases Related to Alcohol and Other

Drug Use 424Carol A Sulis

78 Sleep Disorders Related to Alcohol and Other Drug Use 433Sanford Auerbach

79 Traumatic Injuries Related to Alcohol and Other Drug Use 440Linda C Degutis, David A Fiellin, and

Gail D’Onofrio

80 Endocrine and Reproductive Disorders Related to Alcohol and Other Drug Use 444Alan Ona Malabanan

81 Alcohol and Other Drug Use During Pregnancy: Management of the Mother and Child 448Martha J Wunsch and Michael F Weaver

82 Surgical Interventions in the Alcohol- or Drug-Using Patient 454Daniel P Alford

Section 11.

Co-Occurring Addiction and Psychiatric Disorders

83 Substance-Induced Mental Disorders 459

R Jeffrey Goldsmith, Richard K Ries, and Christine Yuodelis-Flores

84 Co-Occurring Addiction and Affective Disorders 463Edward V Nunes and Roger D Weiss

85 Co-Occurring Addiction and Anxiety Disorders 474Angela E Waldrop, Karen J Hartwell,

and Kathleen T Brady

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86 Co-Occurring Addiction and Psychotic

Disorders 478Douglas Ziedonis, Aurelia N Bizamcer,

Marc L Steinberg, Stephen A Wyatt, David A Smelson, and Adrienne D Vaiana

87 Co-Occurring Addiction and Attention

Deficit/Hyperactivity Disorder 485Frances R Levin, John J Mariani, and Maria A Sullivan

88 Co-Occurring Addiction and Borderline

Personality Disorder 491Linda A Dimeff, Katherine Anne Comtois, and Marsha M Linehan

89 Integrating Psychosocial Services with

Pharmacotherapies in the Treatment of Co-Occurring Disorders 495Joan E Zweben and Richard K Ries

90 Posttraumatic Stress Disorder and

Substance Use Disorder Comorbidity 499Michael E Saladin, Sudie E Back,

and Rebecca A Payne

91 Co-Occurring Addiction and Eating

Disorders 503Lisa J Merlo, Amanda M Stone, and

Mark S Gold

Section 12.

Pain and Addiction

92 The Neurophysiology of Pain and

Interfaces with Addiction 511Peggy Compton, Rollin M Gallagher, and

Issam A Mardini

93 Psychological Issues in the

Management of Pain 518Edward C Covington and Margaret M Kotz

94 Nonopioid Treatments in the

Management of Pain 527James A D Otis and Michael Perloff

95 Opioid Therapy of Pain 531

Seddon R Savage and Ryan Horvath

96 Legal and Regulatory Considerations

in Pain Management 541Aaron M Gilson and Martha A Maurer

Section 13.

Children and Adolescents

97 Epidemiology of Adolescent Substance Use 545Melissa Weddle and Patricia K Kokotailo

98 Preventing Substance Abuse Among Children and Adolescents 549Kenneth W Griffin and Gilbert J Botvin

99 Adolescent Risk and Protective Factors: Psychosocial 552

W Alex Mason and J David Hawkins

100 Neurobiology of Addiction from a Developmental Perspective 554Deborah R Simkin

101 Adolescent Cigarette Smoking 559Terri L Randall and Himanshu P Upadhyaya

102 Screening and Brief Intervention for Adolescents 562Sharon Levy and John R Knight

103 Assessing Adolescent Substance Use 566Ken C Winters, Tamara Fahnhorst,

Andria Botzet, and Randy Stinchfield

104 Adolescent Treatment and Relapse Prevention 569Steven L Jaffe, Ashraf Attalla,

and Diana I Simeonova

105 Placement Criteria and Strategies for Adolescent Treatment Matching 573Marc Fishman

106 Co-Occurring Psychiatric Disorders in Adolescents 579Marie E Armentano, Ramon Solhkhah,

and Deborah R Simkin

H Westley Clark and Anton C Bizzell

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xxxvi Contents

108 Consent and Confidentiality in

Addiction Practice 588

Bonnie B Wilford

109 Clinical and Legal Considerations in

Prescribing Drugs with Abuse

Potential 590

Theodore V Parran, Jr., Robert L DuPont,

and Bruce D Lamb

110 Clinical and Legal Considerations

in Drug Testing 593Robert L DuPont, Bruce A Goldberger, and Mark S Gold

111 Drug Courts and the Treatment of Incarcerated Populations 599The Hon Peggy Fulton Hora (Ret.) and The Hon

William G Schma (Ret.)

Index 603

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C H A P T E R

1

Drug Addiction: The Neurobiology

of Behavior Gone Awry

Repeated drug use leads to long-lasting changes in the brain that undermine voluntary control Psychoactive

drugs (both legal and illegal) are used and misused for various reasons including the following:

The aberrant behavioral manifestations that occur during addiction have been viewed by many as “choices” of

the addicted individual However, recent studies have revealed an underlying disruption to brain regions that

are important for the normal processes of motivation, reward, and inhibitory control in addicted individuals

From a neurobiological perspective, drug addiction is a disease of the brain and the associated abnormal

behavior is the result of dysfunction of brain tissue.

ADDICTION: A DEVELOPMENTAL DISORDER

Normal adolescent-specifi c behaviors (such as risk taking, novelty seeking, and response to peer pressure) increase

the propensity to experiment with legal and illegal drugs This behavior may be due in part to the incomplete

development of brain regions (e.g., myelination of frontal lobe regions) that result in “executive functions” such

as decision making and motivation In addition, drug exposure during adolescence might result in different

neuroadaptations from those that occur during adulthood (e.g., exposing adolescent rodents to nicotine

leads to signifi cant changes in nicotine receptors; this does not occur in adult rodents) Individuals who start

using psychoactive drugs in adolescence are at higher risk of addiction than those who start using drugs later

in life

NEUROBIOLOGY OF DRUGS OF ABUSE

Dopamine has been consistently associated with the reinforcing effects of most drugs of abuse Drugs of abuse

increase extracellular dopamine concentrations in limbic regions, including the nucleus accumbens (NAc)

Drugs of abuse provide longer and larger (5–10-fold) increases in dopamine than natural reinforcers such as

food and sex Some drugs (such as cocaine, amphetamine, methamphetamine, and ecstasy) increase dopamine

directly (by inhibiting dopamine reuptake or promoting dopamine release) Other drugs (such as nicotine,

alco-hol, opiates, and marijuana) work indirectly via other neuron receptors that modulate dopamine levels

Dopamine is involved in many aspects of reward and pleasure, including the prediction of reward and salience Salience refers to stimuli or environmental changes that are arousing or that elicit an

attentional-behavioral switch Salience affects the motivation to seek the anticipated reward and facilitates

conditioned learning This suggests that drug-induced increases in dopamine will inherently motivate further

Summary Author: Christopher SankeyNora D Volkow • Ting-Kai Li

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2 SECTION 1 | Basic Science and Core Concepts

procurement of more drug (regardless of whether or not the effects of the drug are consciously perceived to be

pleasurable) Salience also leads to a situation in which sensory stimuli (sights, sounds, etc.) that are associated

with the drug or with drug taking can increase dopamine by themselves and elicit the desire for the drug This

explains also why the addicted person is at risk of relapsing when exposed to an environment where he or she has

previously taken the drug

NEUROBIOLOGY OF DRUG ADDICTION

From a neurobiologic perspective, addiction probably results from neurobiologic changes that are associated

with recurrent supraphysiologic perturbations in the dopamine system Chronic drug exposure alters the

morphology of neurons in dopamine-regulated circuits At a cellular level, drugs have been reported to alter

the expression of certain transcription factors (nuclear proteins that bind to regulatory regions of genes, thereby

regulating their transcription into mRNA), as well as a wide variety of proteins involved in neurotransmission in

brain regions that are regulated by dopamine At the neurotransmitter level, addiction-related adaptations have

been documented not only for dopamine but also for glutamate, GABA, opiates, serotonin, and various

neuro-peptides In people with addictions, abnormal neurotransmitter levels are found in the mesocortical region of

the brain This brain region contains the orbiofrontal cortex, which is involved in compulsive behavior, as well

as the cingulate gyrus, which regulates disinhibition These adaptations are believed to play a signifi cant role in

aberrant addictive behaviors such as compulsive drug administration and poor inhibitory control, and relapse

VULNERABILITY TO ADDICTION

Genetic Factors

It is estimated that 40% to 60% of the vulnerability to addiction is attributable to genetic factors In humans,

several chromosomal regions have been linked to drug abuse, but only a few specifi c genes have been identifi ed

with polymorphisms (alleles) that either predispose to or protect from drug addiction While much of this research

is still in its infancy, some of the best-known examples of addiction-related polymorphisms are as follows:

The genetic alterations of alcohol dehydrogenase are protective against alcoholism

Environmental factors that have been consistently associated with the propensity to self-administer drugs

include low socioeconomic class, poor parental support, and drug availability Imaging techniques now allow

us to investigate how environmental factors affect the brain and how these, in turn, affect the behavioral

responses to drugs of abuse For example, in nonhuman primates, social status affects D2-receptor expression in

the brain Animals that achieve a dominant status in the group show increased numbers of D2 receptors High

D2 receptor levels have been shown to lead to marked decreases in drug consumption in primates

Comorbidity with Mental Illness

The risk for substance abuse and addiction in individuals with mental illness is signifi cantly higher

than for the general population The high comorbidity probably refl ects, in part, overlapping

environmen-tal, genetic, and neurobiologic factors that infl uence drug abuse and mental illness It has been proposed that

comorbidity might be due to the use of the abused drugs to self-medicate the mental illness In addition, chronic

exposure to psychoactive drugs could lead to neurobiologic changes, which might explain the increased risk of

mental illness This highlights the relevance of the early evaluation and treatment of mental diseases as an

effec-tive strategy to prevent drug addiction that starts as self-medication

STRATEGIES TO COMBAT ADDICTION

The knowledge of the neurobiology of drugs and the adaptive changes that occur with addiction is guiding new

strategies for prevention and treatment

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Preventing Addiction

As we gain knowledge of the genes (and the proteins that they encode) that make a person more or less vulnerable

to taking drugs and to addiction, we will become better at tailoring interventions for those at higher risk For

example, our understanding of the greater neurobiologic vulnerability of adolescents underscores why

preven-tion of early exposure to drugs during adolescence is such an important strategy to combat drug addicpreven-tion

Treating Addiction

The adaptations in the brain that result from chronic drug exposure are long lasting; therefore, addiction must

be viewed as a chronic disease Long-term treatment will be required for most cases, just as for other chronic

diseases (such as hypertension, diabetes, and asthma) This “chronic disease” perspective should modify the

instead as a temporary setback because of lack of compliance or tolerance to an effective treatment

Rates of relapse and recovery in the treatment of drug addiction are very similar to those of other chronic

•

medical diseases

As with other “multisystem” chronic disease, addiction treatment requires the involvement of multiple brain

•

circuits (reward, motivation, learning, inhibitory control, and executive function), and their associated

disrup-tion of behavior indicates the need for a multimodal approach in the treatment of the addicted individual

Pharmacologic Intervention

Pharmacologic interventions can be grouped into two classes:

Those that interfere with the reinforcing effects of drugs of abuse Potential mechanisms for this include

Table 1.1 summarizes proven medications and medications for which there are preliminary clinical data

TABLE 1.1 Medications for Treating Drug and Alcohol Additiona

(Continued)

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4 SECTION 1 | Basic Science and Core Concepts

TABLE 1.1 Medications for Treating Drug and Alcohol Additiona (Continued)

Pyrrolopyrimidine compound (Antalarmin;

George Chrousos et al.)

CRF1 receptor (inhibits stress-triggered responses)

Rimonabant (Acomplia;

Sanofi -Synthelabo)

CB1 receptor (antagonist)Smoking cessation

different pharmacokinetics)

signals)

of DA)Rimonabant (Acomplia;

Sanofi -Synthelabo)

CB1 receptor (antagonist)

Nicotine conjugate vaccine (NicVax; Nabi Biopharmaceuticals)

Blocks entry into brain

Heroin/opiate

addiction

different pharmacokinetics)

Cocaine addiction

HoechstMarionRoussel)

GABA transaminase (inhibits GABA metabolism)

Medications used for physical withdrawal are not included

aAntiepileptic drugs that have been shown to decrease drug induced DA increases as well as conditioned response

FDA, Food and Drug Administration; GABA, g-aminobutyric acid; GABAB, GABA type B; 5HT3, 5-hydroxytryptamine (serotonin)

receptor subtype 3; MAO-B, monoamine oxidase B

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