Vol 9, No 4 - Addictive Substances
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he following review of current pharmacological treatments  for  nicotine, alcohol, cocaine, and  opioid dependence addresses pharmacotherapies aimed at two stages of treatment: (i) acute withdrawal or the initial attainment of abstinence and (ii) chronic maintenance or prevention of relapse. Maintenance pharmacothera- pies act as either blocking or substitution agents to atten- uate protracted withdrawal symptoms. Detoxification is required prior to administration of a blocking agent, in order to prevent withdrawal from an abused agent. For example, naltrexone, a competitive opioid antagonist, completely blocks the subjective euphoria and produc- tion  of  physiological  dependence  of  heroin  use. Substitution agents will not precipitate withdrawal when given to drug-dependent patients, and instead act to reduce withdrawal symptoms and the desire for more drugs. Substitution agents may also produce cross-toler- ance  to  other  drugs  from  the  same  pharmacological class. Methadone  is  one  example  of  an  agent  that  is effective in reducing illicit opioid use by producing cross- tolerance to heroin.The need for these pharmacothera- pies is highlighted by the sharp increase in the rate of even the relatively uncommon abuse of opiates; 12.4% of young adults abused prescription pain relievers in the past year.1,2P h a r m a c o l o g i c a l  a s p e c t s Copyright © 2007 LLS SAS.  All rights reserved www.dialogues-cns.org Therapeutic options and challenges for substances of abuse Tracie J. Gardner, PhD; Thomas R. Kosten, MD T Keywords: addictive disorders; substance abuse Author  affiliations: Assistant  Professor,  Baylor  College  of  Medicine, Menninger Department of Psychiatry and Behavioral Sciences and Michael E. DeBakey  VA  Medical  Center,  Houston,  Texas,  USA  (Tracie  J.  Gardner); Professor  of  Psychiatry,  Neuroscience  and  Addictions,  Baylor  College  of Medicine, Menninger Department of Psychiatry and Behavioral Sciences and Michael  E.  DeBakey  VA  Medical  Center,  Houston,  Texas,  USA  (Thomas  R. Kosten)   Address  for  correspondence: Tracie  J.  Gardner,  PhD,  MED-VAMC,  2002 Holcombe Blvd, (151RSL) Houston, TX 77030, USA (e-mail: tgardner@bcm.edu) Addiction to substances continues to be a significant pub- lic health concern in the United States. The following review of current pharmacological treatments discusses a range of substances: nicotine, alcohol, cocaine, and opi- oids. The goal is to provide an overview of currently avail- able and new pharmacological treatments for substance use disorders, while also addressing the pharmacothera- peutic challenges remaining. The significant advances in pharmacotherapy have had limited utilization, however. For example, naltrexone for alcoholism is infrequently pre- scribed, buprenorphine for opiates still has relatively few qualified prescribers, and stimulants have no Food and Drug Administration-approved pharmacotherapy. These pharmacotherapies are needed, with the rate of even the relatively uncommon abuse of opiates now rising sharply.   © 2007, LLS SAS Dialogues Clin Neurosci. 2007;9:431-445.