Factors Influencing the Effectiveness of Substance Abuse Treatments

Transcription

1 Factors Influencing the Effectiveness of Substance Abuse Treatments Stephen Jurd Area Medical Director Drug and Alcohol Services Northern Sydney Health

2 Patient Factors Social Stability - education, marital status, employment, residential stability all predict good short term outcome Severity predicts AA utilisation AA utilisation predicts long term recovery

3 Treatment Factors Psychological Biological Social

4 Psychological Treatments Something is better than nothing Cost-benefit of 1:4 Sicker people need more Place of inpatient treatment is unsure Structured is better than unstructured Matching hypotheses unclear TSF produced more abstinence at 3 years

5 Biological Treatment for Alcohol Dependence Naltrexone Acamprosate Ondansetron Beware SSRIs SR

6 Naltrexone USA -Volpicelli (1992) O Malley(1992) Anton (1999) Australia -Morris (2001) Latt (2002) Reduction in relapse, reduction in craving, altered subjective intoxication, decreased drinking in a session

7 Comparison 5

8 Results 1

9 Acamprosate Eleven separate, but orchestrated European trials. Now one American trial. Large numbers Consistent reduction in relapse Effect demonstrated out to 12 months Treatment effect sustained 12 months later

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12 Oh, wait! Wait, Cory!... Add the cereal first and then the milk!

13 Comparing and Combining Naltrexone and Acamprosate in Relapse Prevention of Alcoholism From: Kiefer: Arch Gen Psychiatry, Volume 60(1).January Figure 2. Curves of the survival probabilities toward the event relapse for each of the treatment groups (Breslow test: t 3 = 13.87, P =.003). Significant differences emerged between naltrexone and placebo (P =.02), between acamprosate and placebo (P =.05), and between the combined medication and placebo (P =.008). In addition, the combined medication was more effective than acamprosate (P =.04).

14 Comparing and Combining Naltrexone and Acamprosate in Relapse Prevention of Alcoholism From: Kiefer: Arch Gen Psychiatry, Volume 60(1).January Figure 3. Curves of the survival probabilities toward the event first alcohol intake (lapse) for each of the treatment groups (Breslow test: t 3 = 29.25, P <.001). Significant differences emerged between naltrexone and placebo (P =.03), between acamprosate and placebo (P =.04), and between the combined medication and placebo (P =.002). In addition, the combined medication was significantly more effective than acamprosate (P =.04

15 Nalmefene Opiate antagonist, like naltrexone, but with no hepatotoxicity Beginning marketing out of Finland Also decreases relapse in alcohol dependence - Mason 1999

16 Comparison 2

17 Ondansetron Decreases relapse in alcohol dependence Only early onset alcohol dependence responded Only one study (Johnson et al, JAMA 2000) Large numbers (270), well designed and presented study Moderate effect size

18 Beware SSRIs Ondansetron finding Kranzler found that fluoxetine decreased the effect of CBT and increased the relapse rate in Type B alcoholics Pettinati(2000) found sertraline did not benefit Type B alcoholics Murmurings re fluvoxamine

19 SR Cannabinoid antagonist Promising results in animal studies Human studies underway

20 Biological Treatment for Opiate Dependence LAAM Methadone Buprenorphine Naltrexone

21 New Drugs - Old Concepts Addiction is a disease Craving is a physical phenomenon Addicts reward themselves chemically

22 New Drugs - New Concepts Several neurotransmitters are relevant Combination drug treatment may be appropriate There may be pharmacological subtypes of alcohol dependence

23 Social Intervention Community Reinforcement approach Impaired Physicians Programs Taxes

24 Independent Factors Substitute Dependencies i.e.habit New love relationship i.e.love Religious Involvement i.e.god Behaviour Modification i.e.control

25 Further Reading 1 Volpicelli et al (1992) Naltrexone in alcoholism Arch Gen Psychiat NDARC Report on NEPOD study (2001) O Brien and McLellan Myths of Addiction (1996) Lancet Pettinati (2000) Alc Clin Exp Res

26 Further Reading 2 Montgomery et al AA involvement and recovery1995 J. Substance Abuse Treatment Latt et al Naltrexone in alcohol dependence MJA : G Vaillant Natural History of Alcoholism Revisited Harvard Uni Press 1997 Sass, Soyka et al 1996 Acamprosate in alcohol dependencearch Gen Psychiat

27 Nicotine Prevalence now below 20% Global pandemic Nicotine replacement (gum, patch, inhaler) Buproprion Counselling