A Perspective on the Selected Recent Research In the Addiction Field

Substance use disorders are among the most common psychiatric problems that clinicians confront. Because of this, attention to this issue of Focus should be of particular value to psychiatric practitioners.

In the past, residency training programs gave limited attention to this area of practice. More recently, residency programs have been required to include supervised clinical experience on these disorders, but most psychiatry departments have few faculty members who specialize in this area. The Influential Publications and Abstract sections of this issue of Focus highlight important areas of recent research in the addiction field.*

Alcohol is the substance most likely to bring a patient or family member to the attention of the practitioner. In recent years, medications useful in decreasing cravings for alcohol, oral naltrexone and acamprosate and a depot naltrexone, have come available. Although these medications have the advantage of embedding the encounter between clinicians and alcoholic patients in a pharmacologically grounded context, we still have to rely heavily on psychosocial approaches for engaging patients in treatment and ensuring a long-term beneficial outcome. This point is particularly important as we have little long-term, community-based experience with these medications to shed light on their impact on the chronic and relapsing illness of alcohol dependence. Two options available for more durable impact of the clinician's efforts are presented in recent papers. The first is engaging the spouse of the alcoholic in facilitating treatment, particularly because it is typically the spouse who bears the brunt of the patient's pathology and is most likely to press for treatment. Fals-Stewart and colleagues (abstract, page 188) presented the results of a study of ambulatory alcoholic patients who were treated with a modality that involved spousal support. A detailed manual of the modality they applied is available on the Internet, and the reader is encouraged to refer to it.

The second option is promotion of the engagement of the alcoholic patient in Alcoholics Anonymous (AA). Recent research has shown that a professionally implemented technique, Twelve-Step Facilitation, can be successfully used in this regard. Two issues of importance with regard to AA, however, are the role of Twelve-Step programs in promoting an abstinent outcome, and their potential for cost savings. Humphreys and Moos (page 193) demonstrate that when programs are oriented toward the use of this approach, they apparently achieve a better outcome on both counts.

Marijuana is the most common drug abused by adolescents in treatment programs, and its use is certainly pandemic among them. According to recent survey findings, one half of twelfth graders were reported to have ever used this drug, and one quarter of them had used it within the previous month. Many of these users regard use of this drug as harmless and recreational, but a body of research reviewed by Arseneault and colleagues (page 270) points to the drug's being a contributing factor to the later onset of schizophrenia in some patients. This review has obvious clinical implications for adolescent patients and their families. It also presents an excellent model for the reader to understand the use of epidemiological techniques in clarifying difficult clinical conundrums, in this case, whether a particular drug of abuse is a cause, a result, or a concomitant occurrence of general psychiatric illness.

The recent introduction of buprenorphine as an office-based treatment for opioid dependence has been one of the most valuable contributions of psychopharmacology to the treatment of substance use disorders. This medication is useful in numerous manifestations of this clinical problem, from intravenous use of heroin to overreliance on narcotic analgesics and from detoxification to long-term maintenance. The use of buprenorphine for opioid maintenance therapy is an important area of clinical use. Of importance, however, there has been limited research on the psychosocial approaches in which successful buprenorphine maintenance can be embedded. Because patients taking buprenorphine can override the effect of this medication by injecting heroin in large doses, it is important that a modality be available for promoting cessation of such illicit use and for addressing concomitant abuse of other drugs, the latter being a common problem heroin addicts. Galanter and associates (abstract, page 190) have applied network therapy to this problem. It utilizes family and peer support and is designed for use in office space practice. Descriptions of the clinical techniques applied in a controlled study such as theirs typically are short in research articles, but a more extensive description of how this modality is applied can be found in the American Psychiatric Publishing Textbook on Substance Abuse Treatment. This text is a very useful resource to clinicians for their work with substance-abusing patients.

Our attempts to find pharmacologic agents that can be used in the treatment of cocaine addiction have yet to yield clinically significant success. A variety of dopaminergic and γ-aminobutyric acid-related medications have been tested with limited impact, and clinical trials on a cocaine vaccine have yet to be reported. Two medications, however, have recently been found to yield increased duration of cocaine abstinence and reduced use in controlled clinical trials. One is modafinil, which has psychostimulant properties similar to those of sympathomimetic drugs but its mechanism of action is different from that of amphetamine-related agents and its apparent abuse potential is limited. It has been used successfully in the treatment of narcolepsy and shift work sleep disorder. Dackis and associates (abstract, page 189) report on its effectiveness in the treatment of cocaine-dependent patients, and the fact that the effect of the medication may derive from its glutamate-enhancing action, because repeated cocaine administration depletes extracellular glutamate.

Many alcohol abusers are more likely to turn to cocaine when intoxicated. Because of this, disulfiram was thought to have potential in the treatment of cocaine dependence. Carroll and associates (abstract, page 191), however, have found that disulfiram has an apparent unique role in such treatment, independent of its potential for yielding diminished alcohol use. This role is well illustrated in their paper that also demonstrates how a pharmacologic agent, disulfiram in this case, and a psychosocial treatment, cognitive behavior therapy, can each be effective in addiction treatment.

The widespread publicity for abuse of anabolic androgenic steroids by sports figures has enhanced the appeal of these drugs for risk-taking adolescents who want to build up their bodies. Thus, it has become increasingly important for clinicians to recognize how abuse of anabolic steroids can play an important role in engendering the psychopathology observed among many adolescents and young men. The review article by Trenton and Currier (abstract, page 190) provides a useful overview of this clinical problem and its management. General psychiatric disorders and symptoms are associated with these drugs, particularly mood disorder and less commonly psychosis. The paper also addresses stabilization of the patient. Treatment should be familiar to the clinician, even though the handling of such issues may be more appropriately referred to specialized drug treatment professionals.

Testimony regarding substance abuse impairment is particularly complex because there are many gray areas associated with proper assessment, and the clinician may have to exercise considerable judgment if presented with the need for consultation or testimony. Gendel (abstract, page 190) reviewed the topics that arise in the large number of related forensic issues that clinicians increasingly encounter, ranging from evaluation for competency and disability to child custody and determination of criminal responsibility.

When one looks at the issue of addictive disorders from the perspective of different cultures, certain observations inevitably shed light on the parochial nature of American understanding and judgment about addiction. These include culture-bound biases that color our presumably objective understanding of the impact of certain drugs and which treatments are most effective. For this reason, the review by Robin Room (page 199) of cultural and social influences on our understanding of drug abuse is most informative.

Electronic technology has gained increasing attention for a variety of applications in psychiatric practice. The use of telephone contact to maintain continuity of care and treatment follow-up may provide the clinician with an important option, particularly in geographic areas where face-to-face contact over time may be difficult to arrange, and where a clinician's reach needs to be extended to a large number of patients. McKay and associates (abstract, page 189) write about the effectiveness of such a telephone-based approach.

To review recent salient clinical research overall, my colleague, Helen Dermatis, and I have prepared a clinical synthesis article (page 141). We address recent pharmacologic approaches to alcohol, opioid, cocaine, and tobacco dependence and also present an overview of psychosocial treatments for people with a combination of a general psychiatric disorder and substance dependence.