Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

26. Psychopharmacological Treatments 591tine dependence is 75–100 mg daily, but it should be used with caution in thosewith cardiovascular disease given its possible effects on cardiac function. Likebupropion, nortriptyline is an antidepressant and may be useful in the treatmentof depressed cigarette smokers. Another antidepressant related medication,selegiline, an MAO inhibitor, has shown some recent efficacy in reducingsmoking (George et al., 2003).Finally, clonidine, a noradrenergic alpha 2agonist that decreases centralsympathetic activity, may be an effective treatment for those who do not wantnicotine replacement therapy or who have failed other smoking cessationmethods.ALCOHOL PHARMACOTHERAPIESAcute Withdrawal MedicationsAcute withdrawal from alcohol is a serious medical condition that can precipitateadrenergic activation, seizures, or delirium tremens, a condition with up to15% mortality when untreated (Kosten & O’Connor, 2003). The current standardapproach to alcohol detoxification uses tapering dosages of benzodiazepines,such as chlordiazepoxide or clonazepam, which are effective in relievingthe autonomic hyperactivity of withdrawal and will prevent seizures. Benzodiazepinesare initially made available on an as-needed basis, with parameters fordosing based on appearance of withdrawal symptoms including agitation,diaphoresis, tremor, hypertension, and tachycardia. Withdrawal symptoms canbe assessed over the course of the detoxification using the Clinical InstituteWithdrawal Assessment of Alcohol Scale, revised (CIWA-Ar; Sullivan,Sykora, Schneiderman, Naranjo, & Sellers, 1989). This extensively studiedscale has been shown to have good reliability, reproducibility, and validity. Thescale measures 10 symptoms associated with withdrawal, each of which can bescored in increasing severity on a scale of 0–7 (with the exception of orientationand clouding of sensorium, which are scored on a scale of 0–4. Scoresabove 10 indicate a need for medication to treat withdrawal symptoms. Furthermore,the CIWA predicts that those with a score of greater than 15 are atincreased risk for severe alcohol withdrawal, with higher scores conveyinghigher risk. Although detoxification schedules must be individualized, a benzodiazepinetaper can usually be accomplished in 3–4 days. Patients with hepaticdisease should be detoxified with lorazepam or oxazepam, shorter-acting drugsthat, unlike the other benzodiazepines, have no active metabolites requiringhepatic clearance. Lorazepam is also a good choice for detoxification of thepatient with severe vomiting, because it is well absorbed by the intramuscularroute of administration.Anticonvulsants have been shown to be equal in effectiveness to benzodiazepinesin the treatment of alcohol withdrawal (Malcolm, Myrick, Brady, &Ballenger, 2001). Multiple studies support the efficacy of sodium valproate