APA guideline update focused on substance abuse treatment

A new injectable medication for the treatment of alcohol dependence, as well as a novel pharmacotherapy for nicotine addiction, were the focus of the American Psychiatric Association’s update to its Practice Guideline for the Treatment of Patients with Substance Abuse Disorders, 2nd Edition

The update in 2007 supplements the information and recommendations published in the 2006 version of the guideline. It provided additional evidence in favor of a long-acting, injectable form of the drug naltrexone, which was FDA approved in oral form for the treatment of alcohol dependence in 1994. The efficacy of the oral form was limited by patient noncompliance to the regimen.

While the injectable delivery was mentioned in the 2006 version as a possible aid to adherence, it had not yet received FDA approval at the time of publication. The updated guideline cited data from a manufacturer-sponsored, multisite, randomized controlled trial, in which once-monthly injectable naltrexone was found to significantly improve medication exposure and drinking outcomes. There currently is insufficient evidence on the efficacy of naltrexone in patients not seeking treatment for alcohol dependence such as incarcerated individuals or those court-ordered to undergo treatment.

Additional findings on alcohol dependency interventions were reported in the COMBINE study, a multisite, controlled trial investigating pharmacotherapy and behavioral interventions alone or in combination, with or without adjunctive substance abuse behavioral counseling. Medications investigated included naltrexone, acamprosate and placebo, with and without behavioral intervention or medication management.

Study results indicated that during a 16-week treatment, all groups undergoing therapy with pills and medication management (including placebo pills) showed significant improvement in percentage of days of alcohol abstinence. Notably, patients undergoing specialized behavior intervention without pills or medication management showed the least improvement. While acamprosate was well tolerated, it was not more effective than placebo.

The guideline update also addressed a new pharmacotherapy for the treatment of nicotine addiction. Varenicline has partial agonist activity at neuronal nicotinic acetylcholine receptors, and it has demonstrated consistent superiority to placebo in five multisite, randomized controlled trials.

For more information:

Connery HS. Focus (Am Psychiatr Publ.) 2007; 5:1-4.