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Conditioning approaches have been used in some settings in the treatment of alcoholism, most commonly as a type of aversion therapy For example, the patient is given a drink of whiskey and then a shot of apomorphine, and proceeds to vomit In this way a strong association is built up between the drinking and vomiting Although this kind of treatment has been successful in some cases, many people do not sustain the learned aversive response
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1 Alcoholic hallucinosis Alcoholic hallucinosis, which can occur either during or on cessation of a prolonged drinking period, is not a typical withdrawal syndrome and is handled differently Since the symptoms are primarily those of a psychosis in the presence of a clear sensorium, they are handled like any other psychosis: hospitalization (when indicated) and adequate amounts of antipsychotic drugs Haloperidol, 5 mg orally twice a day for the first day or so, usually
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tions should not be given prior to thiamine for fear of precipitating Wernicke s syndrome Thiamine is necessary as a ketolase enzyme cofactor Concurrent administration is satisfactory, and hydration should be meticulously assessed on an ongoing basis Chronic brain syndromes secondary to a long history of alcohol intake are not clearly responsive to thiamine and vitamin replenishment Attention to the social and environmental care of this type of patient is paramount
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The comments in the section on problem drinking apply here also; these methods of treatment become the primary consideration after successful treatment of withdrawal or alcoholic hallucinosis Psychological and social measures should be initiated in the hospital shortly before discharge This increases the possibility of continued post-hospitalization treatment
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Anton RF et al; COMBINE Study Research Group Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial JAMA 2006 May 3;295(17):2003 17 [PMID: 16670409] Dongier M What are the treatment options for comorbid alcohol abuse and depressive disorders J Psychiatry Neurosci 2005 May;30(3):224 [PMID: 15944746] Mayo-Smith MF et al Management of alcohol withdrawal delirium An evidence-based practice guideline Arch Intern Med 2004 Jul 12;164(13):1405 12 Erratum in: Arch Intern Med 2004 Oct 11;164(18):2068 dosage error in text [PMID: 15249349] Ringold S et al JAMA patient page Alcohol abuse and alcoholism JAMA 2006 May 3;295(17):2100 [PMID: 16670424] Williams SH Medications for treating alcohol dependence Am Fam Physician 2005 Nov 1;72(9):1775 80 [PMID: 16300039]
OTHER DRUG & SUBSTANCE DEPENDENCIES 1 Opioids
The terms opioids and narcotics are used interchangeably and include a group of drugs with actions that mimic those of morphine The group includes natural derivatives of opium (opiates), synthetic surrogates (opioids), and a number of polypeptides, some of which have been discovered to be natural neurotransmitters The principal narcotic of abuse is heroin (metabolized to morphine), which is not used as a legitimate medication The other common opioids are prescription drugs that differ in milligram potency, duration of action, and agonist and antagonist capabilities (see 1) All of the opioid analgesics can be reversed by the opioid antagonist naloxone The clinical symptoms and signs of mild narcotic intoxication include changes in mood, with feelings of euphoria; drowsiness; nausea with occasional emesis; needle tracks; and miosis The incidence of snorting and inhaling heroin ( smoking ) is increasing, particularly among cocaine users This coincides with a decrease in the availability of methaqualone (no longer marketed) and other sedatives used to temper the cocaine high (see discussion of cocaine under Stimulants, below) Overdosage causes respiratory depression, peripheral vasodilation, pinpoint pupils, pulmonary edema, coma, and death
Dependency is a major concern when continued use of narcotics occurs, although withdrawal causes only moderate morbidity (similar in severity to a bout of flu ) Addicted patients sometimes consider themselves more addicted than they really are and may not require a withdrawal program Grades of withdrawal are categorized from 0 to 4: grade 0 includes craving and anxiety; grade 1, yawning, lacrimation, rhinorrhea, and perspiration; grade 2, previous symptoms plus mydriasis, piloerection, anorexia, tremors, and hot and cold flashes with generalized aching; grades 3 and 4, increased intensity of previous symptoms and signs, with increased temperature, blood pressure, pulse, and respiratory rate and depth In withdrawal from the most severe addiction, vomiting, diarrhea, weight loss, hemoconcentration, and spontaneous ejaculation or orgasm commonly occur Complications of heroin administration include infections (eg, pneumonia, septic emboli, hepatitis, and HIV infection from using nonsterile needles), traumatic insults (eg, arterial spasm due to drug injection, gangrene), and pulmonary edema Treatment for overdosage (or suspected overdosage) is naloxone, 2 mg intravenously If an overdose has been taken, the results are dramatic and occur within 2 minutes Since the duration of action of naloxone is much shorter than that of the narcotics, the patient must be under close observation Hospitalization, supportive care, repeated naloxone administration, and observation for withdrawal from other drugs should be maintained for as long as necessary Treatment for withdrawal begins if grade 2 signs develop If a withdrawal program is necessary, use methadone, 10 mg orally (use parenteral administration if the patient is vomiting), and observe If signs (piloerection, mydriasis, cardiovascular changes) persist for more than 4 6 hours, give another 10 mg; continue to administer methadone at 4- to 6-hour intervals until signs are not present (rarely more than 40 mg of methadone in 24 hours) Divide the total amount of drug required over the first 24-hour period by 2 and give that amount every 12 hours Each day, reduce the total 24-hour dose by 5 10 mg Thus, a moderately addicted patient initially requiring 30 40 mg of methadone could be withdrawn over a 4- to 8-day period Clonidine, 01 mg several times daily over a 10- to 14-day period, is both an alternative and an adjunct to methadone detoxification; it is not necessary to taper the dose Clonidine is helpful in alleviating cardiovascular symptoms but does not significantly relieve anxiety, insomnia, or generalized aching There is a protracted abstinence syndrome of metabolic, respiratory, and blood pressure changes over a period of 3 6 months Narcotic antagonists (eg, naltrexone) can also be used successfully for treatment of the patient who has been free of opioids for 7 10 days Naltrexone blocks the narcotic high of heroin when 50 mg is given orally every 24 hours initially for several days and then 100 mg is given every 48 72 hours Liver disorders are a major contraindication Compliance tends to be poor, partly because of the dysphoria that can persist long after opioid discontinuance Buprenorphine, a partial agonist, is approved for office-based management of opiate addiction Its use requires special training Alternative strategies for the treatment of opioid withdrawal have included rapid and ultrarapid detoxification techniques However, recent data do not support the use of
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