Addiction Medicine: Closing the Gap between Science and Practice

The comprehensive assessment should result in
a treatment plan that is developed in concert
with the patient by a physician with input from
other health professionals. The treatment plan
should articulate clearly the treatment goals and
particular interventions aimed at meeting each of
those goals. The plan should be monitored and
revised as needed should the patient’s status or
needs change.^18

The comprehensive assessment also should
result in a detailed and thorough written report,
which should be incorporated into the patient’s
health record, that:

 Provides a clinical diagnosis and identifies
the particular manifestations and severity of
the disease;

 Identifies factors that contribute to or are
related to the disease;

 Identifies a treatment plan to address these
risk factors and ensure that the treatment
plan is implemented and monitored
effectively; and

 Provides connections to specialty care--i.e.,
an addiction physician specialist or other
specialty providers--as needed and to
auxiliary and support services.^19

Stabilization*

The first step in addressing addiction involving
nicotine, alcohol or other drugs is cessation of
use and, if necessary, medically managing the
clearance of toxic substances from the patient’s
system via a clinical process often referred to as
detoxification. Detoxification itself addresses
intoxication or withdrawal but is not treatment
of addiction.^20 In most cases, cessation of use is
the necessary first step to formal treatment
protocols. While cessation of use can in some

• Note that some of the medications described for use

in the stabilization (tobacco cessation and
alcohol/other drug detoxification) process will be
described in greater detail later in this chapter in the
discussions of acute treatments for addiction and
chronic disease management.

cases be a self-managed process, patients

typically need professional assistance.

Cessation of Use ..........................................................................................................

Tobacco. Smoking cessation, while unpleasant

for most persons going through it, is not unsafe

and does not require medical monitoring.

Patients undergoing smoking cessation may

experience certain withdrawal symptoms

including cravings, irritability, impatience,

hostility, anxiety, depressed mood, difficulty

concentrating, decreased heart rate, increased

appetite and sleep disturbances.^21 The calming

effect many smokers feel when smoking usually

is associated more with the relief of nicotine

withdrawal symptoms than with the effects of

the nicotine itself. Withdrawal symptoms can

commence in as little as a few hours after the

last dose of nicotine, peak within a few days,

and either subside within several weeks or, in

some cases, persist for months.^22

Nicotine replacement therapy (NRT)--through

the use of nicotine patches, gum, nasal spray,

inhalers, lozenges and sub-lingual tablets--is a

common pharmaceutical aid for persons

attempting smoking cessation. NRT lessens

withdrawal symptoms, increasing the chance

that a smoker will quit successfully.^23 NRT

replaces some of the nicotine formerly obtained

by smoking.^24 However, the nicotine in NRT is

delivered more slowly and at lower dose levels

than through smoking, so NRT is more likely to

reduce cravings than wholly eliminate them.^25

Some NRTs mimic the sensations of smoking

(the inhaler) or otherwise occupy the mouth

(gum, lozenges and sub-lingual tablets).^26

Research indicates that the most effective use of

NRT involves replicating the experience of

smokers: using nicotine patches to maintain a

baseline serum nicotine level along with the gum

or lozenges to produce a boost of serum nicotine

levels periodically.^27

Other pharmaceutical therapies such as

antidepressants (bupropion SR) and nicotine

agonists (varenicline) can help people quit