The roots of addiction medicine began in the ancient civilisations of Africa and Europe. Special methods to care for persons addicted to alcohol were developed in ancient Egypt. There are references to individuals considering chronic intoxication as a sickness that enslaved the body and soul dating back to the fifth century BC.

Native American healers used botanical agents (hop tea) to suppress cravings for alcohol, and the root of the trumpet vine to induce aversion to alcohol. In 1774, Anthony Benezet published the book ‘Mighty Destroyer Displayed’, where he observed that intoxication had a tendency to self-accelerate: “Drops beget drams, and drams beget more drams, till they become to be without weight or measure.”

We have come a long way since. Modern treatments encompass a bio-psycho-social approach that integrates neuropharmacology, psychotherapy, and social interventions. Addiction is multidimensional and disrupts many aspects of an individual’s life. A similarly multimodal approach is needed to treat it.

Pharmacotherapy helps the individual remain abstinent and thus functional in the family, at work, and in society. Among people who are unable to quit a drug after repeated treatment failures, the treatment goal changes to reducing the frequency of substance use and the severity of relapse. Combined treatments with pharmacotherapy and psychotherapy can lead to better treatment retention and outcomes.

Intoxication states

Intoxication results from being under the acute influence of a drug. It typically produces pleasurable feelings, altered emotional responsiveness, altered perception, and impaired judgement. Intoxication states can range from euphoria or sedation to life-threatening emergencies when overdose occurs. The initial challenge to the clinician is diagnosis, as intoxication can mimic other psychiatric conditions. 

The assessment involves a thorough patient history, physical and mental state examination, and laboratory screening. The first priority is general supportive care and resuscitative action to ward potential life-threatening complications off. The assessment also involves ascertaining the severity of the substance ingestion, a patient’s level of consciousness, substances involved, and co-occurring disorders.

Standardised questionnaires are available for use by the clinician and the patient. However, acute intoxication may impede an individual’s ability to provide information, so that can also be obtained from the patient’s family. Toxicology screens provide information regarding the types of substances used. Urine is the most widely used specimen because of the ease of obtaining a sample, the relatively high concentrations of drugs and metabolites present in urine, and the stability of the metabolites when frozen.

Testing for alcohol is done via breathalyser, blood alcohol levels, and urine tests. Laboratory assays that measure increase in liver enzymes — such as gamma-glutamyl transferase, aspartate aminotransferase, alanine aminotransferase, and carbohydrate-deficient transferrin — indicate possibly heavy use. Serum-based phosphatidyl ethanol detects the presence of even a few days of heavy alcohol consumption for up to three weeks after use.

Withdrawal management

Withdrawal management is an entry-point into treatment and by itself does little to change long-term drug abuse. This comprises the attenuation of the physiological and psychological features of withdrawal syndromes. Hospitalisation becomes relevant in the context of acute intoxication, severe or complicated withdrawal, co-occurring conditions that complicate management, failure of treatment engagement, and life-threatening complications.

Patients with addiction exhibit varied clinical presentations, from acute and subacute to chronic manifestations. The treatment response is contingent on the substance used, the presence or absence of a compromised cardiopulmonary system, and the underlying health status of the patient. 

Under the care of a psychiatrist, addicted individuals are systematically withdrawn from drugs in an inpatient or outpatient setting. Withdrawal management is intended to reduce or eliminate the medical consequences of withdrawal, the pain of withdrawal, and cravings. Many risks are associated with substance use withdrawal.

For example, in persons with severe alcohol dependence, an abrupt, untreated cessation of drinking may result in marked hyper-autonomic signs, seizures, withdrawal delirium, or even death. Medications are available for tapering from alcohol, nicotine, opioids, benzodiazepines, barbiturates, and other sedatives.

Withdrawal management alone does not address the associated psychological, social, and/or behavioural problems. It is conceived as early treatment engagement — preceding a full continuum of services.

Neuropharmacological management

Recognising intoxication and withdrawal states is critical to appropriately manage individuals with addiction. Psychiatrists are able to recognise the unique intoxication and withdrawal states of particular substances, and treat patients who are under the influence of or are experiencing withdrawal from substances. The treatment involves an appreciation of the natural history of the disorder and a complete assessment of the patient’s psychiatric status.

There are two general strategies for pharmacological management: suppressing withdrawal via a cross-tolerant medication and reducing the signs and symptoms of withdrawal by altering another neuropharmacological process. A longer-acting medication is typically used to provide a milder, controlled withdrawal. Examples include the use of methadone for opioid detoxification and chlordiazepoxide for alcohol detoxification.

Detoxification alone doesn’t constitute the full-spectrum of management — but in most general hospital settings, patients are discharged after the detoxification process without longer-term anti-craving management. Data show that around 50% of patients with alcohol use disorder relapse within three months of detoxification without longer-term anti-craving management.

The U.S. Food and Drug Administration has approved disulfiram, naltrexone, and acamprosate to treat alcohol addiction. In the Indian setting, in addition to these molecules, baclofen and topiramate are also used.

Forms of therapy

Studies have demonstrated that therapy or counselling can be an effective treatment for some addictions. Therapy attempts to arrest compulsive, addictive behaviours via the modification of behaviours, feelings, social functioning and thoughts. This involves attempts to increase motivation, expand the coping repertoire, implement reinforcement strategies to increase the frequency of positive behaviours, improve mood, and enhance interpersonal connection and the number of social supports.

Cognitive-Behavioural Therapy: Cognitive-behavioural therapy (CBT) is based on the premise that learning processes play a critical role in the development of maladaptive patterns of behaviour.

CBT targets two processes: dysfunctional thoughts and maladaptive behaviours. Thought-based interventions focus on increasing the patient’s resolve not to use — based on negative and positive consequences of use — and confronting thoughts about use. Relapse prevention is a form of CBT.

The goal of relapse prevention is to help addicted individuals learn to identify and correct problematic behaviours. Specific techniques include exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings early on, identifying situations that pose high risk of use, developing better coping strategies, and avoiding high-risk situations which may compel drug use. Anticipating problems that patients are likely to encounter and then developing effective coping strategies forms the crux of relapse prevention. 

Motivational Enhancement Therapy: Motivational enhancement therapy (MET) is a patient-centered counselling approach that initiates behaviour change by helping patients resolve their ambivalence about engaging in treatment and stopping drug use.

MET employs strategies to evoke rapid and internally motivated change in the patient, rather than guiding the patient stepwise through the recovery process. MET provides feedback generated from an initial assessment to stimulate discussion regarding personal substance use and to elicit self-motivational statements.

Motivational interviewing principles are also used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the client. Over time, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or to sustained abstinence. 

Remarkable advances have occurred in the treatment of addiction. Research in the domains of genetics, molecular biology, and brain imaging have advanced our understanding of addiction. This has also paved the way for safe and effective treatments. Examples abound of complete recovery from this relapsing brain disorder. When dealing with addiction, it is vital to have endless hope.

Alok Kulkarni is a senior interventional neuropsychiatrist at the Manas Institute of Mental Health and Neurosciences at Hubli, Karnataka.