Guest Editorial
Twinning Research and Practice Guidelines in the Management of Addictions
Nady el-Guebaly, MD, FRCPC1
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The last decade witnessed deliberate attempts by those working in the field of addictions to narrow the gap between research-based insights and daily clinical practice. This issue’s In Review articles reflect the breadth and depth of addiction research, with a particular focus on investigations conducted in Canada. Each article attempts to identify guidelines relevant to clinical practice.
Dr Monica Zilberman and colleagues’ article on sex differences and psychiatric comorbidities in substance use disorders is the result of an international collaboration between the gender study group in Sao Paulo, Brazil; Dr. Sheila Blume, a pioneer in the field from the State University of New York; and our own group at the University of Calgary. This paper reports higher prevalence rates of psychiatric comorbidities with substance use disorders among women in both general population and treatment samples. A higher proportion of these comorbid disorders is primary among women, while the reverse is true for men. The authors outline the clinical characteristics of women with psychiatric comorbidity, particularly depression, and review the relevance of comorbidity to outcome. Despite its significance, analysis of sex difference is preliminary at best in pharmacologic and psychotherapeutic clinical trials.
Dr Juan Negrete’s update on substance abuse in persons with schizophrenia is a compendium of current therapeutic experience, offered by a seasoned clinician and researcher in this area. The article details well the complex interaction of addiction and schizophrenia and outlines the elements of a well-organized integrated therapy program. The paper concludes with a brief review of emerging pharmacotherapy and psychotherapy strategies addressing this population. This paper is a “must-read” for all clinicians who treat those afflicted with schizophrenia and who are bound to encounter the challenges raised by substance abuse.
The third review article, by Dr Hermano Tavares and colleagues, discusses cognitive-behavioural therapy (CBT) approaches to pathological gambling. It presents several challenges, including the question, What are the similarities and differences between addiction to substances and behavioural addictions? Pathological gambling is still listed in the DSM-IV as an impulse control disorder, while most practitioners apply the treatment approaches of substance dependence to this behavioural disorder. Tavares and colleagues identify cognitive and behavioural distortions specific to gambling, as well as consequent treatment techniques, with attention to practical “how to” details that will aid individual practitioner and clinical teams dealing with the problem. The article also challenges basic tenets of traditional multimodal approaches to addiction. Gambling as an activity is culturally sensitive, and further testing of treatment approaches across cultural groups is recommended.
In 1999, NIDA published a consensual set of general research-based principles underlying effective treatment (1). The articles in this series further the development of practice guidelines. These emerging guidelines are critical as an increasing array of empirically based therapeutic strategies are becoming available to clinicians, including the following:
Advances in pharmacology that make available an increasing number of medications specific to our field, rather than borrowed from other psychiatric conditions, such as anticraving medication (for example, naltrexone or acamprosate) or pharmacotherapy for opiate addictions (for example, methadone or buprenorphine). Sequential psychotherapeutic interventions targeted to the various stages of change and including an array of behavioural and cognitive-behavioural approaches (for example, CBT, contingency management, and cue extinction). These strategies aim at promoting the resolve to stop addictive behaviour, at mastering alternate coping skills, and at achieving stable and contented recovery. The recent development of several manualized guides to therapy is an important tool for fostering the emerging standardized management approaches. Addressing the comorbidities. Of particular interest to psychiatrists is the long-standing association between addictions and other mental disorders. The search for novelty and euphoria, as well as self-medication, are at play in this interaction. Younger people with severe mental disorders who live in the community and have some financial resources, but are frustrated in their hopes to lead a productive life, are at particular risk for addiction. Trials with traditional psychiatric pharmacotherapy are beginning to include substance users. Lessons from the behavioural addictions. The loss of control underpinning several behaviours has been identified as characteristic of addictions. Although one must exercise caution here and not outstrip the empirical evidence, insights emerging from the study of addictive behaviours not related to drug use are reframing our fundamental understanding of reward and cognition. The application of traditional therapeutic strategies for substance use to behavioural addictions is another expanding field.
Psychiatrists and other colleagues in the health professions who practise in the addictions field will be challenged and rewarded by the interaction between an exploding knowledge base, an opportunity for systematic community planning, and the wisdom of mutual help. Welcome aboard!
References
1. National Institute on Drug Abuse. Principles of drug addiction treatment. A research- based guide. Rockville (MD): NIH Publications; 1999. 99–4180.
Author(s)
1. Professor and Head, Substance Abuse Division, University of Calgary, Calgary, Alberta.
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