NIH - National Institutes On Drug Abuse (NIDA) Basis for Effective Treatment

http://www.drugabuse.gov/ResearchReports/methamph/methamph3.html#long

Scientific research since the mid-1970s shows that treatment can help many people change destructive behaviors, avoid relapse, and successfully remove themselves from a life of substance abuse and addiction. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. Based on this research, key principles have been identified that should form the basis of any effective treatment program:

1. No single treatment is appropriate for all individuals. 2. Treatment needs to be readily available. 3. Effective treatment attends to multiple needs of the individual, not just his or her drug addiction. 4. An individuals treatment and services plan must be assessed often and modified to meet the persons changing needs. 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. 6. Counseling and other behavioral therapies are critical components of virtually all effective treatments for addiction. 7. For certain types of disorders, medications are an important element of treatment, especially when combined with counseling and other behavioral therapies. 8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. 9. Medical management of withdrawal syndrome is only the first stage of addiction treatment and by itself does little to change long-term drug use. 10. Treatment does not need to be voluntary to be effective. 11. Possible drug use during treatment must be monitored continuously.

12. Treatment programs should provide assessment for hiv/aids, hepatitis b and c, tuberculosis,
and other infectious diseases, and should provide counseling to help patients modify or change behaviors that place themselves or others at risk of infection. 13. As is the case with other chronic, relapsing diseases, recovery from drug addiction can be a long-term process and typically requires multiple episodes of treatment, including "booster" sessions and other forms of continuing care.

CO-OCCURRING DISORDERS AMONG PEOPLE WITH STIMULANT USE DISORDERS Stimulant users have a surprising number of co- or preexisting disorders that can make differential diagnosis challenging or complicate treatment. Recently, investigators have become more interested in the implications of premorbid conditions as potential indicators of vulnerability to stimulant dependence. Majewska points out the need for more research to establish the epidemiological relationships between preexisting neurological deficits resulting from genetic, developmental, traumatic, or neurotoxic factors and vulnerability to drug addiction. More specifically, preclinical studies and some surveys seem to indicate that neurological deficits associated with AD/HD, neuroanatomical abnormalities, lead poisoning, alcoholism, posttraumatic brain lesions, and posttraumatic stress disorder (PTSD) may be correlated with increased vulnerability to stimulant addiction. Identified anxiety, phobias, AD/HD, and antisocial personality disorder typically precede cocaine dependence, whereas alcoholism, depression, and paranoia generally follow stimulant use. Although the symptoms of stimulant-induced psychosis closely mimic those of schizophrenia, and heavy use of cocaine/amphetamines may precipitate latent schizophrenia, the two disorders are not closely correlated. Differentiating comorbid psychiatric disorders from stimulant-related disorders can be challenging. Acute or chronic stimulant intoxication can elicit symptoms of anxiety that are indistinguishable from phobias, obsessive compulsiveness, panic, and generalized anxiety. Withdrawal from stimulants can cause depression that is indistinguishable from major depression from other causes (Gold and Miller, 1997). It can take at least a month of abstinence from all stimulant use to differentiate stimulantinduced dysphoria, depression, paranoia, or anxiety from a true psychiatric disorder. The prognosis for substance use disorders is worsened by the presence of other untreated psychiatric disorders (or substance use disorders). Clients with comorbid psychiatric and drug dependence disorders need to have both treated; the psychiatric problems usually improve with abstinence. Antidepressant and neuroleptic medications with low anticholinergic and sedative properties are preferred in order to avoid another addiction. Sedative-hypnotics and benzodiazepines must be used with caution in high-risk populations.

MEDICAL CONDITIONS What Does Methamphetamine Do to the Brain? Methamphetamine's adverse effects on the brain are clear. In animals, methamphetamine damages nerve terminals in brain regions containing dopamine and serotonin, two chemicals essential for normal functioning of the central nervous system. Similarly, in humans, methamphetamine alters the brain in ways that impair decision-

making, memory, and motor behaviors, and causes structural and functional deficits in brain areas associated with depression and anxiety. Dopamine cell death, however, has not been documented in methamphetamine abusers, which could explain why extended abstinence allows for some recovery from methamphetamine-induced deficits in dopamine function (Figure 2). But even though a recent neuroimaging study of methamphetamine abusers showed partial recovery of brain function in some regions following protracted abstinence, function in other regions did not display recovery even after two years of abstinence7ndash; suggesting that long-lasting and even permanent brain changes may result from methamphetamine abuse.

METHAMPHETAMINE AND HIV In addition to its harmful effects on the brain, methamphetamine is inextricably linked with HIV, hepatitis C, and other sexually transmitted diseases. Its abuse increases the risk of contracting HIV not only through the use of contaminated injection equipment, but also through increased risky sexual behaviors and through physiological changes that may favor HIV transmission. Methamphetamine abuse may also affect HIV disease progression. For example, clinical studies suggest that current methamphetamine abusers on highly active antiretroviral therapy may be at greater risk of developing AIDS than non-users, possibly due to poor medication adherence or interactions between methamphetamine and HIV medications. Similarly, preliminary studies suggest that interactions between methamphetamine and HIV itself may lead to more severe consequences for HIV-positive patients who abuse methamphetamine, including greater brain damage and cognitive impairment. More research is needed to better understand these interactions.

Is continued drug abuse a voluntary behavior? The initial decision to take drugs is mostly voluntary. However, when drug abuse takes over, a person's ability to exert self control can become seriously impaired. Brain imaging studies from drug-addicted individuals show physical changes in areas of the brain that are critical to judgment, decisionmaking, learning and memory, and behavior control.7 Scientists believe that these changes alter the way the brain works, and may help explain the compulsive and destructive behaviors of addiction. Why do some people become addicted to drugs, while others do not? As with any other disease, vulnerability to addiction differs from person to person. In general, the more risk factors an individual has, the greater the chance that taking drugs will lead to abuse and addiction. "Protective" factors reduce a person's risk of developing addiction. What factors determine if a person will become addicted?

No single factor determines whether a person will become addicted to drugs. The overall risk for addiction is impacted by the biological makeup of the individual - it can even be influenced by gender or ethnicity, his or her developmental stage, and the surrounding social environment (e.g., conditions at home, at school, and in the neighborhood). Which biological factors increase risk of addiction? Scientists estimate that genetic factors account for between 40 and 60 percent of a person's vulnerability to addiction, including the effects of environment on gene expression and function. Adolescents and individuals with mental disorders are at greater risk of drug abuse and addiction than the general population.

What are the basics of effective addiction treatment? Research shows that combining treatment medications, where available, with behavioral therapy is the best way to ensure success for most patients. Treatment approaches must be tailored to address each patient's drug abuse patterns and drug-related medical, psychiatric, and social problems. How can medications help treat drug addiction? Different types of medications may be useful at different stages of treatment to help a patient stop abusing drugs, stay in treatment, and avoid relapse.

Treating Withdrawal. When patients first stop abusing drugs, they can experience a variety of physical and emotional symptoms, including depression, anxiety, and other mood disorders; restlessness; and sleeplessness. Certain treatment medications are designed to reduce these symptoms, which makes it easier to stop the abuse. Staying in Treatment. Some treatment medications are used to help the brain adapt gradually to the absence of the abused drug. These medications act slowly to stave off drug cravings, and have a calming effect on body systems. They can help patients focus on counseling and other psychotherapies related to their drug treatment. Preventing Relapse. Science has taught us that stress, cues linked to the drug experience (e.g., people, places, things, moods), and exposure to drugs are the most common triggers for relapse. Medications are being developed to interfere with these triggers to help patients sustain recovery.

How do behavioral therapies treat drug addiction? Behavioral treatments help engage people in drug abuse treatment, modifying their attitudes and behaviors related to drug abuse and increasing their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Moreover, behavioral therapies can enhance the effectiveness of medications and help people remain in treatment longer. How do the best treatment programs help patients recover from the pervasive effects of addiction? Getting an addicted person to stop abusing drugs is just one part of a long and complex recovery process. When people enter treatment, addiction has often taken over their lives. The compulsion to get drugs, take drugs, and experience the effects of drugs has dominated their every waking moment, and drug abuse has taken the place of all the things they used to enjoy doing. It has disrupted how they function in their family lives, at work, and in the community, and has made them more likely to suffer from other serious illnesses. Because addiction can affect so many aspects of a person's life, treatment must address the needs of the whole person to be successful. This is why the best programs incorporate a variety of rehabilitative services into their comprehensive

treatment regimens. Treatment counselors select from a menu of services for meeting the individual medical, psychological, social, vocational, and legal needs of their patients to foster their recovery from addiction.

The clinician should ensure that a treatment plan is developed cooperatively with the person seeking treatment, that the plan is followed, and that treatment expectations are clearly understood. Medical, psychiatric, and social services should also be available. Because some problems (such as serious medical or mental illness or criminal involvement) increase the likelihood of patients dropping out of treatment, intensive interventions may be required to retain them. After a course of intensive treatment, the provider should ensure a transition to less intensive continuing care to support and monitor individuals in their ongoing recovery.