Faculty Bibliography

This issue of Primary Psychiatry focuses on the ever-increasing biologic treatments for addiction, and how clinicians can integrate those modalities into broader psychosocial treatments. Although addiction is most certainly a brain disease, it is not only a brain disease. As anyone who treats addicted or dually diagnosed patients knows, the presenting problem's complexity usually necessitates some combination of biologic and psychological remedies. The wide-ranging and biologically distinct modalities in this issue will be presented as useful parts of the more complete treatment package. Readers will find new clinical tools, an understanding of where science is heading, and renewed hope for patients in their battles against addiction and mental illness.

Can new medications help in the treatment of substance use disorders? The short answer to that question is yes. Despite the historical resistance of addiction treaters to using medications in their treatment of addicted people, recent advances and more sophisticated methods for integrating medications into standard addiction treatment have led to a surge in new anti-addiction medications available to the addicted person. Medications like depot naltrexone and acamprosate have shown substantial effects in decreasing alcohol craving, while suboxone has provided relief to opiate addicts who simply would not have come to treatment in the past. Despite the apparent post-marketing emergence of side effects like agitation and nightmares, varenicline is a step in the right direction for those looking for help with their nicotine addiction. Although not yet available to the public, the pipeline of investigational medications includes several cocaine vaccines. In addition to these vaccines and the Food and Drug Administration-approved medications, other addiction remedies have been touted in the press and should be understood by the general physician; in this widely publicized but unproven category is the proprietary medication 'cocktail' offered by Prometa. Clinicians can provide substantial benefit to their addicted patients by making newly developed medications part of the treatment package. This article reviews the clinical use of these new medications

(from the journal abstract) Alcohol use disorders (AUDs) frequently affect the course of mental illness. Alcohol can both cause and exacerbate symptoms and must be treated concurrently with the psychiatric illness. Similar to personality disorders, alcohol can cause or worsen symptoms, though often in a more hidden manner. Treatment for dually diagnosed individuals with alcoholism and mental illness consists of an integration of addiction and mental illness treatment paradigms, use of peer-led support groups, a 'coaching' therapy style, and medication regimens tailored to each patient's specific syndromes. Specific psychotherapeutic modalities useful for dually diagnosed patients include relapse-prevention psychotherapy, motivational interviewing, cognitive-behavioral psychotherapy, and social skills training groups. The clinician must modify the treatment regimen on an ongoing basis to address symptoms of alcoholism or mental illness as they appear. Using research data and case examples, this article provides a model for the treatment of individuals diagnosed with mental illness and AUDs.

(from the journal abstract) Knowledge that a patient with a psychiatric disorder is a chronic marijuana smoker presents the clinician with a dilemma: should the patient be treated even with ongoing use of marijuana or should the patient be advised to stop smoking? Although these decisions are made on a case-by-case basis, it would be helpful if some basic guidelines could be developed for treatment decisions in these cases. This article reviews some of the findings from recent research and combines it with the clinical experience of the authors in order to provide some help in understanding the difficulties patients have in discontinuing marijuana and of the ways in which continued use may complicate efforts to treat the underlying psychiatric disorder.

(from the journal abstract) This article reviews the epidemiology of substance use disorders in the United States. Some basic epidemiological definitions are noted, as well as a few important confounding factors specific to the epidemiology of the substance use disorders. Results are presented from some well-known household, treatment, law-enforcement, and population-specific surveys. The special case of addicted physicians is examined in depth, as is the most recent apparent epidemic of heroin use. Finally, some data from large treatment and outcome studies are presented, along with the author's conclusions.

On July 26, 1990, the U.S. Congress enacted the Americans with Disabilities Act (ADA), which was intended as a broad, national, civil rights-oriented mandate 'for the elimination of discrimination against individuals with disabilities,' both physical and mental. ADA protection is extended, in limited form, to those with addiction disorders. However, many addicted individuals are denied ADA protection because of exclusionary criteria in the ADA itself and because of increasingly restrictive interpretations of the ADA in recent cases. The benefit to the addicted persons, and to the larger society, is lost when unfair discriminatory practices preclude employment of otherwise qualified, though stigmatized, individuals. The ADA currently falls short, in many respects, of preventing such discrimination against those with addictions

The authors assessed sociodemographic, drug use, and diagnostic correlates of protracted homelessness in a sample of 147 dually diagnosed patients who required admission to the hospital. When 58 patients with protracted homelessness, defined as continuous undomiciled status for over a year, were compared with 74 patients without protracted homelessness, significant differences were found with regard to diagnosis, employment status, criminality, Brief Psychiatric Rating Scale score on admission, and history of injection drug use. The results of a multiple logistic regression analysis confirmed that a history of injection drug use, current unemployment, and a diagnosis of schizophrenia were positively associated with a history of protracted homelessness. No significant relationships were obtained between protracted homelessness and demographics or chronicity of mental illness

This study was designed to assess whether cocaine abuse was associated with a different set of antecedents and course for hospitalized schizophrenic patients. Forty-three cocaine-using and 27 non-cocaine-using patients with schizophrenia admitted to a dual diagnosis unit were compared with regard to antecedents to hospitalization such as prior treatment episodes, reliance on drugs for pleasure and tension reduction, and criminal history as well as course of hospital treatment. Cocaine-using patients were more likely to have had a history of prior inpatient drug treatment and to rely on drugs to a greater extent for tension reduction and pleasure. There was a trend for cocaine users to have a history of arrests for violent crimes. Although cocaine-using patients exhibited lower levels of global distress during the first week of hospitalization, they were no different from their counterparts who abused nonpsychostimulant drugs with regard to outcome of hospital treatment. These findings suggest that the lifetime course of illness among schizophrenic patients presenting for hospitalization who abuse cocaine may be characterized by episodes of repeated inpatient drug treatment and impaired impulse control. More rigorous discharge planning and aftercare program monitoring in the community as well as stress management interventions directed to tension reduction are therefore warranted