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

638 V. TREATMENTS FOR ADDICTIONSBriefly, greater severity of substance dependence, presence and severity ofcomorbid psychiatric problems, lower levels of social support, and unemploymenthave consistently related to poorer outcome reviews (McLellan &McKay, 1998). Larger scale studies have also demonstrated with some consistencythat addressing comorbid issues and problems in treatment is generallyassociated with improved outcome (McLellan, Arndt, Metzger, Woody, &O’Brien, 1993; McLellan, Grissom, Zanis, & Randall, 1997).Thus, appropriate matching to treatment implies provision of an effective,empirically supported therapy, with adjunct therapies appropriate to the specificco-occurring problems, as dictated by careful, thorough, assessment of thepatient functioning and status across a range of domains. This review summarizesempirically supported therapies across the most common substance use disorders(SUDs), with special emphasis on how pharmacological and behavioraltherapies can be combined to enhance outcome. When available, data regardingthe types of individuals who may respond particularly well or poorly to specificapproaches are reviewed. First, however, it is important to understand therespective roles of pharmacotherapy and behavioral approaches in terms of howthese may be tailored, or combined, to meet the needs of specific individuals.ROLES OF PHARMACOTHERAPY IN THE TREATMENTOF SUBSTANCE USE DISORDERSThe target symptoms addressed and roles typically played by pharmacotherapydiffer from those of behavioral treatments in their course of action, time toeffect, target symptoms, and durability of benefits (Elkin, Pilkonis, Docherty, &Sotsky, 1988). In general, pharmacotherapies have a much more narrow applicationthan do most behavioral treatments for SUDs; that is, most behavioraltherapies are applicable across a range of treatment settings (e.g., inpatient,outpatient, residential), modalities (e.g., group, individual, family), and to awide variety of populations. For example, disease-model, behavioral, or motivationalapproaches have been used, with only minor modifications, regardless ofwhether the patient is an opiate, alcohol, cocaine, or marijuana user. On theother hand, most available pharmacotherapies tend to be applicable only to asingle class of substance use and exert their effects over a narrow band of symptomsor clinical settings. For example, methadone produces cross-tolerance foropioids but has little effect on concurrent cocaine abuse; disulfiram producesnausea after alcohol ingestion, but not after ingestion of illicit substances. Anotable exception is naltrexone, which is used to treat both opioid and, morerecently, alcohol dependence.Common roles and indications for pharmacotherapy in the treatment ofsubstance dependence disorders are presented (Carroll, 2001; Rounsaville &Carroll, 1997).