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http://www.medscape.com/viewarticle/743648?src=mp&spon=12

Dr. Herbert D. Kleber spoke at symposium
Prof of Psych & Director of the Division of Substance Abuse at the Columbia & NY State Psych Inst
talk titled "The Elusive Goal of Psychostimulant Dependence Pharmacotherapy"

brief introduction to the central effects of cocaine and amphetamines
when administered acutely, these drugs incr synaptic dopamine, norepi, and ser (monoamines)
tx using agonists for monoamines may reduce drug dependence
possible adverse cardiovascular effects

monoamine agonists
d-methamphetamine
methylphenidate-sustained release
d-amphetamine-sustained release
these enhance retention in psychostimulant abuse treatment

potential utility of disulfiram, used to tx alcohol dependence
blocks dopamine beta hydroxylase-->increases ratio of dopamine to norepinephrine
assessed in 7 studies, n=over 300 total

other agents
modafinil
bupropion = dopamine and norepinephrine reuptake inhibitor, reduces subjective effects of psychostimulants and decr craving in initial lab studies

effectiveness
antagonist approaches less effective, require a high level of motivation

vaccines vs cocaine being studied: slows crossing bbb but doesn't affect metabolism
decreasing euphoric effects
no adverse effects in early trials

naltrexone decreases dopaminergic effects of stimulants
decr opioidergic activity

indirect antagonists
unequivocal results
topiramate, gabapentin, and vigabatrin

maybe work better in combination
desipramine, levodopa, and bupropion
with contingency management strategies

nothing works yet for meth

**************************
Cannabis Dependence

Frances R. Levin, MD speaking
little research on pharm options
most widely used illicit drug in us and world
"adolescents comprise 40% of substance abuse treatment admissions for cannabis addiction"
delta-9-tetrahydrocannabinol is key active agent
DSM4 has no cannabis withdrawal diagnostic category
"there is clearly a withdrawal syndrome experienced by chronic, heavy users"
sx: decr appetite, irrit, nervousness/anx, restlessness, sleep problems, anger/aggression, craving

some things that work
motivational interviewing, cognitive-behavioral therapy
family structural therapy (used primarily for adolescents and their families)
contingency management strategies
tx-->less use, amount and freq
aerobic exercise (v small trial)

potential pharm
agonists, antagonists, partial agonists, tx sx, tx comorbid conditions
some research on divalproex; bupropion; nefazodone; mirtazapine; quetiapine; baclofen
high doses appeared to reduce cannabis craving
naltrexone appeared to enhance the subjective effects of cannabis while not affecting withdrawal sx

oral tetrahydrocannabinol and rimonabant
reviewed by FDA for obesity but not approved
dt adverse effects: dysphoria and suicidal ideation

combination of dronabinol and lofexidine being studied

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