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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses pharmacologic dilemmas in the treatment of addiction, including the treatment of insomnia among patients with substance use disorders, the pharmacologic treatment of attention-deficit\/hyperactivity disorder (ADHD) among patients with substance use disorders, alcohol pharmacotherapy, as well as opioid agonist and antagonist therapies.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPsychopharmacology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESubstance-Related Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPsychiatry\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPsychopharmacology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESubstance-Related Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPsychiatry\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAn American Psychiatric Association symposium dealt with pharmacologic dilemmas in the treatment of addiction.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EINSOMNIA\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EKirk J. Brower, MD, University of Michigan Health System, Ann Arbor, Michigan, USA, discussed the treatment of insomnia among patients with substance use disorders. Alcoholics frequently and persistently experience problems sleeping [Zhabenko N et al. \u003Cem\u003EClin Exp Res\u003C\/em\u003E 2012], which can drive relapsed drinking [Malcolm R et al. \u003Cem\u003EJ Clin Sleep Med\u003C\/em\u003E 2007] and even suicidal tendencies [Klimkiewicz A et al. \u003Cem\u003EDrug Alcohol Depend\u003C\/em\u003E 2012]. Abstinence is no guarantee that insomnia will end soon, with a return to normal sleep requiring months to several years depending on the aspect of sleep [Brower K et al. \u003Cem\u003EAm J Addictions\u003C\/em\u003E 2011; Brower K. \u003Cem\u003EAlcohol Res Health\u003C\/em\u003E 2001]. Contributing factors to insomnia include substances or medications, premorbid insomnia, co-occurring disorders (medical, psychiatric, other), environmental factors, and inadequate sleep hygiene.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EIn alcohol-dependent patients who are suffering from insomnia, the clinician should always assume that alcohol is a responsible factor but be cognizant that it may not be the only factor. So, reduction in drinking, preferably abstinence, is a necessary and reasonable first-line treatment. Reducing or eliminating alcohol may not be a complete answer, since those dependent on alcohol can have other psychiatric and medical disorders associated with insomnia, as well as sleep disorders such as sleep apnea and periodic limb movements, and can be experiencing increased stress. These other factors can be most productively addressed by behavioral therapy, pharmacotherapy, or both.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EA sleep diary can be useful in assessing sleep patterns. A diary kept for several weeks early in treatment can also help the clinician evaluate the patient and delay prescribing medications that might prove to be unwarranted. Validated sleep questionnaires, including the Sleep Problems Questionnaire and the Insomnia Severity Index, can be useful assessment instruments. Nonprescription sedatives, including antihistamines and supplements (eg, melatonin, valerian), are popular but lack evidence-based rigor. Medications approved by the United States Food and Drug Administration (FDA) are benzodiazepine receptor agonists, ramelteon, and doxepin. Dr. Brower cautioned against using benzodiazepine receptor agonists, since no randomized controlled trials involving postwithdrawal insomnia among alcoholics have been published and because of the possibility of drug abuse and overdose in combination with alcohol and other medications. While studied, the data on trazodone, quetiapine, and gabapentin are not sufficiently robust to recommend these drugs.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EATTENTION-DEFICIT\/HYPERACTIVITY DISORDER\u003C\/h2\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EFrances R. Levin, MD, Columbia University Medical College, New York, New York, USA, discussed the pharmacologic treatment of attention-deficit\/hyperactivity disorder (ADHD) among patients with substance use disorders. ADHD that is diagnosed during childhood can persist into adulthood and has been linked to increased substance use disorder in this population [Kessler RC et al. \u003Cem\u003EAm J Psychiatry\u003C\/em\u003E 2006]. Identification and treatment of ADHD among substance abuse patients is important (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15858\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15858\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15858\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003EImportance of Attention-Deficit\/Hyperactivity Disorder Among Substance Abusers Seeking Treatment\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-8\u0022\u003ESeveral treatments have been recommended for co-occurring substance use disorders and ADHD. Atomoxetine is a first-line treatment, particularly for abstinent alcohol-dependent patients [Wilens TE et al. \u003Cem\u003EDrug Alcohol Depend\u003C\/em\u003E 2008]. Bupropion is used off-label and is not FDA approved for ADHD [Mariani JJ, Levin FR. \u003Cem\u003EAm J Addiction\u003C\/em\u003E 2007]. Modafinil and tricyclic antidepressants are also used off-label. Guanfacine is on-label for ADHD. Stimulants can be used but cautiously and only when indicated [Schubiner H. \u003Cem\u003ECNS Drugs\u003C\/em\u003E 2005]. Frequent patient monitoring for adverse side effects is necessary [Wilson JJ, Levin FR. \u003Cem\u003EJ Child Adolesc Psychopharmacol\u003C\/em\u003E 2005]. Nonpharmacologic adjunctive therapies include cognitive-behavioral therapy and group or individual psychotherapy [Wilens TE. \u003Cem\u003EPsychiatr Clin North Am\u003C\/em\u003E 2004].\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EThe risk of misuse or diversion (ie, selling) of medications prescribed for ADHD is a reality that clinicians need to be aware of. Attention paid to \u201cred flags\u201d of misuse or diversion is prudent (eg, patient demand for particular medication, repeated lost prescriptions, discordant pill count). The goal is to achieve a balance between the risk of undertreatment and that of misuse or diversion.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EALCOHOL\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EKathleen Brady, MD, PhD, Medical University of South Carolina, Charleston, South Carolina, USA, discussed alcohol pharmacotherapy. Alcohol dependence is heterogeneous, and identifying the subtype is paramount for gainful therapy (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15859\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15859\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15859\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003ECharacteristics of Alcohol Subtypes\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EThe FDA-approved medications include disulfiram, naltrexone, and acamprosate. However, the key to pharmacotherapy is compliance. This is problematic for chronic diseases in general and alcohol treatment in particular, given that \u0026lt;50% of patients take medications as prescribed and 40% to 60% relapse within a year [McLellan AT et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2000]. A long-acting injectable formulation of naltrexone that sustains plasma levels of the opioid antagonist for a month reduced the frequency of heavy drinking in a study involving \u0026gt;600 subjects [Garbutt JC et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2005]. A randomized controlled trial that compared the effects of naltrexone and acamprosate (alone or in combination) among 1383 subjects reported the benefit of the former for reducing drinking [Anton RF et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EGlutamate directly stimulates the release of dopamine. The influence on associative learning may have benefits in behavioral changes that reduce drinking. The antiseizure drug topiramate, which potentiates GABA-ergic transmission, appears effective in reducing episodes of heavy drinking [Johnson BA et al. \u003Cem\u003ELancet\u003C\/em\u003E 2003]. Other GABA-ergic\/glutamatergic agents that are being assessed are baclofen, vigabatrin, and gabapentin.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOPIOID USE DISORDERS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EHilary S. Connery, MD, PhD, Harvard Medical School, Boston, Massachusetts, USA, discussed the selection of opioid agonist and antagonist therapies. The approach is safe and can double the success rate of opioid abstinence. Paramount among the variety of symptoms is anxiety, which can drive relapse and discontinuation of treatment. Opioid withdrawal can also be harmful among pregnant women, people with cardiovascular difficulties, and patients with diabetes, for example.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EOpioid medications act differentially. The \u03bc-opioid receptor antagonists (naltrexone, naloxone) and agonists (buprenorphine, methadone) and the \u03b1-2 adrenergic receptor agonist clonidine are used in the early stage of opioid withdrawal. The goal of treatment then becomes maintenance of abstinence. Drugs used here include naltrexone extended release, buprenorphine\/naloxone tablet or suboxone film, and methadone.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003E\u03bc-Opioid receptor agonists can be commenced immediately as a means of weaning a subject off opioids but require a prescription and are given in a clinic setting. A lapse or termination of medication will lead to opioid withdrawal. Antagonists are given when a subject is opioid-free. This delay to treatment can increase chance of relapse, which can increase the risk of opioid overdose. Other important aspects of treatment are diet, exercise, and other forms of stress reduction. The overriding aim is to maintain treatment.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/8\/26.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzp8pp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzp8pp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}