Abstract
On first glance, a book on chemical addictions which covers the topics: nicotine dependence, alcohol dependence in women, opiate dependence, HIV and dual-diagnosis would appear to be somewhat unbalanced. However, as explained in the introduction to this series, this is a collection of monographs forming part of the Annual Review of Psychiatry published by the American Psychiatric Press; and this booklet on addictions is one of six topics that overlap and relate to one another.
Nicotine dependence
Between a quarter and a third of the general population of most countries in the Western world smoke cigarettes. There is a high prevalence of comorbid nicotine dependence among depressed and psychotic patients. About one-third of smokers try to quit each year but less than 10% are able to complete 1 year of total abstinence; most relapsing within days. However, even among those who successfully maintain 1 year of abstinence, further relapses occur. This chapter outlines the basic pharmacology of nicotine, explains well how to assess a smoker for dependence, for the level of motivation and self-efficacy for stopping. It has an up-to-date treatment section and a good discussion of nicotine dependence comorbid with psychiatric illness.
Alcohol dependence, women, biology and pharmacotherapy
As this chapter points out, despite considerable progress in the last decade in our understanding of alcohol dependence, there still exist large gaps in our knowledge around problematic drinking in women. The chapter reviews the physiological differences in the manner in which alcohol is metabolised by females. It also summarises the very small amount of literature on gender difference in behavioural psychology in response to alcohol. It discusses women, alcohol and depression; and women, alcohol and anxiety; noting that in animal studies there are gender differences in which neurosteroids interact with receptors that are influenced by alcohol.
The authors point out that very few women have been enrolled in the many studies of the newer medications such as Acamprosate and Naltrexone, which may be helpful for relapse prevention agents. The authors indicate areas for future research.
Opiate dependence and current treatments
The USA, as well as Australia, has been hit by a substantial new epidemic of heroin abuse. Currently, more young adults are using heroin; the heroin that is available on the streets is purer; there is an increasing number of overdose deaths. The chapter contains an excellent review of the neurobiology of opiate dependency and discusses both the psychosocial and pharmacological treatment of chronic opiate dependency. It devotes a section to the newer pharmacotherapies (L-alpha acetyl methadol (LAAM) and Buprenorphine).
Substance abuse and HIV diseases
This chapter points out that many healthcare providers share the misunderstanding (layered with moralism and stigma) of society in general with respect to substance abuse, particularly in this setting. The chapter outlines particular difficulties in managing an HIV-positive individual in the presence of chaotic substance abuse behaviour. It briefly discusses the assessment and management of these people. Likewise, particularly in the USA, chaotic substance abuse is a risk factor for HIV transmission. There is a section on the specific issues of mental health treatment in the context of the HIV-infected substance abuser.
Issues in dual diagnosis
The authors indicate that perhaps a quarter of individuals with an anxiety disorder would also have a substance abuse disorder and that substance abuse disorders are found in about a third of patients with an affective disorder. Of those individuals presenting for the treatment of opioid abuse, females are twice as likely as males to have an Axis I disorder and males are perhaps twice as likely as females to have an Axis II disorder. The assessment and evaluation of such individuals is outlined in this chapter. The authors point out that in an individual with a psychiatric disorder, failure to recognise that there is a comorbid substance abuse disorder often results in an unsatisfactory response to treatment. Psychosocial interventions in conjunction with psychopharmacology should produce the best improvement in the patient's symptoms. The authors recognise the need for ongoing research to gain a better understanding of the context and solutions of dual diagnosis.
Summary
Substance use disorders are common and commonly missed or ignored in patient populations visiting general practitioners and psychiatrists. This book contains information helpful to medical practitioners in the understanding, assessment and management of these patients.