Pharmacological treatments for heroin and cocaine addiction.
OBJECTIVE
To provide an overview of the pharmacological options for the treatment of heroin- and cocaine-dependent patients based on known biochemical pathways to addiction and the chronic disease model as a starting point for treatment planning.


RESULTS
Recent pre-clinical and clinical studies indicate that different brain structures and different neurotransmitters are involved in different stages of the addiction process. In addition, clinical experience shows that heroin and cocaine addiction can best be conceptualised and treated as a chronic, relapsing disorder with the following treatment goals: crisis intervention, cure or recovery (detoxification, relapse prevention) and care or partial remission (stabilization and harm reduction). The various high-quality studies, systematic literature reviews and formal meta-analyses clearly demonstrate that today many proven effective interventions are available for crisis intervention, detoxification, stabilization and harm reduction for heroin-dependent patients. Interventions directed at relapse prevention are still problematic and only effective in a minority of motivated patients in stable living conditions and adequate social support. In contrast, no proven effective pharmacological interventions are available for the treatment of cocaine-dependent patients, maybe with the exception of some patient groups that seem to benefit from treatment with disulfiram or amantadine. Treatment innovations are primarily based on experimental animal studies. Newly developed cannabinoid receptor antagonists and cortisol synthesis inhibitors show great promise.


CONCLUSIONS
Heroin addiction is a chronic relapsing disease that is difficult to cure, but stabilization and harm reduction can greatly increase the life time expectancy and the quality of life of the patient, his direct environment and society as a whole. Currently, no proven effective pharmacological interventions are available for cocaine addiction, and treatment has to rely on existing cognitive behaviour therapies combined with contingency management strategies.
van den Brink
Wim
W
Department of Psychiatry, Academic Medical Center, University of Amsterdam, Tafelbergweg 25, 1105 BC Amsterdam, The Netherlands. wvandenbrink@amc.uva.nl
van Ree
Jan M
JM
D002908:Chronic Disease; D019970:Cocaine-Related Disorders / Q000503:physiopathology / Q000628:therapy*; D006556:Heroin Dependence / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D010600:Pharmacology / Q000379:methods*; D010913:Pituitary-Adrenal System / Q000503:physiopathology; D012008:Recurrence; D016896:Treatment Outcome