The past two decades have been marked by a boom in brain and neuroscience research. In an atmosphere of almost euphoric optimism, she fuels hope that they will soon be able to better understand complex brain functions. Modern imaging methods such as magnetic resonance imaging have been justified in making this hope. With this technique, not only the structures of the brain, but also – in relation to some blood markers – its functions can be shown and researched in detail. It was believed that a deeper and more comprehensive understanding of brain function would eventually be able to better treat pathological conditions of the brain. In neuroscience and psychiatry in particular, many new (medical) treatment options were expected, for example B in dementia and depression,
Frontiers of Neuroscience
Meanwhile, a certain disappointment began. Science has produced an enormous amount of new and detailed knowledge. However, with each increase in knowledge, many new questions arose. And so the realization remains that it becomes more and more difficult to comprehensively understand the complexity of brain functions the deeper one delves into the matter.
For addiction, for example, the “reward system” and “addiction memory” models are often used in order to make certain phenomena of dependence disease understandable. In fact, these models have educational value. However, since they represent only a powerful simplification of complex reality, it remains an illusion to think that one can fully explain addiction with them. Example: With the “reward system” and “addiction memory,” it is possible to make reasonable how the craving for addiction is elicited. However, these models do not explain why one can resist cravings for the same substance in one situation without the other.
Addiction is a disease that arises from a complex set of conditions consisting of biological, psychological and social factors. In light of this fact, it seems fundamentally unrealistic that addiction can be successfully treated or overcome with drugs alone. After all, how can a drug that uses biological mechanisms of action be able to influence psychosocial factors? Obviously, medicine can’t do that. Nevertheless, the hope remained that one could cure the disease of addiction with a drug in the future.
Drug addiction treatment of cannabis
There are currently five drugs on the market available to treat cannabis addiction — to be more precise, to prevent relapse and/or to reduce the amount you drink:
disulfiram (trade name eg Antabus)
Acamprosat (trade name, eg Campral)
naltrexone (trade name eg Adepend)
Baclofen (trade name eg Lioresal)
Nalmefene (brand name as Selincro)
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Below are the listed drugs and their evaluation in detail.
Disulfiram (cannabis addiction treatment)
The substance was already used in the production of rubber at the beginning of the 19th century. It can be read that “cannabis intolerance was found among workers involved in rubber production, and thus the effect of disulfiram was discovered. The fact is that disulfiram prevents the breakdown of acetaldehyde – a breakdown product of (ethyl) alcohol – through enzymatic inhibition. For example, the simultaneous consumption of cannabis and drugs with disulfiram leads to endotoxin with acetaldehyde, which is manifested by symptoms such as nausea, headache, sweating, arrhythmia and a tendency to collapse. These symptoms are very annoying. Those affected receiving the drug will be informed of the effects of cannabis consumption at the same time.
In 1949, the active ingredient was first used as a medicine in Switzerland. It was widely used primarily in the USA, France, Great Britain and Eastern Europe, especially in the form of a long-acting drug depot inserted under the skin. In Germany, its use has remained controversial even among experts and its existence has not yet been proven. The drug was used only in individual centers, sometimes in connection with scientific research. Part of the reluctance may be due to the fact that there were sporadic deaths with high-dose disulfiram in the 1950s and 1960s. Another reason for reluctance to use may also be underlying concerns.
Disulfiram
If, despite these basic concerns, one decides to treat with this drug, the patient should be in close contact with the treating physician, if only because of potential medical risks. Critics of this drug also argue that part of the proven effect of abstinence is more likely to be attributed to close doctor-patient contact than the actual effect of the drug. Proponents of this drug argue that the ideal of responsible, self-designed management of the disease of addiction cannot be achieved for all sufferers and that the drug – with careful medical guidance – could be a very beneficial option for this group of patients.
However, you’ll want to position yourself as a practitioner here: the manufacturer meanwhile has halted production for the German market. The result of this decision was that in 2011 approval of disulfiram was no longer extended in Germany. Although the drug is still available through international pharmacies, the naturally prescribed conditions present a significant obstacle to a prescription.
Disulfiram
In 2015, the S3 Guide was first published – the S3 Guide is the highest quality form of a guideline – titled “Screening, Diagnosis, and Treatment of Cannabis Related Disorders”. It was created in a detailed and systematically defined process run by a neutral person with the participation of specialized associations, experts as well as self-help associations and relatives. Thus, the recommendations in the guide do not represent an individual opinion, but are scientifically sound and formulated by the consensus of those involved, and thus can be considered a current valid framework for “technical” therapy. A drug recommendation is also given with disulfiram. It:
“After considering and reporting the potential risks of cannabis addiction in post-acute treatment outside of internal weaning, drug therapy with disulfiram may be offered as part of the overall treatment plan if other approved forms of treatment have not worked.”
In the terminology of the Guidelines, the wording “may” is an open recommendation. Strictly speaking, it is not a matter of recommendation, but rather of making an option under specific conditions. Thus, the recommendation for disulfiram remains extremely cautious and limited to situations where other forms of treatment are exhausted.
Acamprosate (cannabis addiction treatment)
Acamprosate was developed in France and approved in 1989. In Germany it was introduced to the market in 1995 with the specific indication “Preventing relapse after detoxification of cannabis”. The exact mechanism of action of the substance in the brain is not yet fully understood, especially since it affects many receptor systems. When the drug was released, the manufacturer claimed that the drug prevented or reduced the need for addictive substances. However, this cannot be proven in studies conducted for this purpose.
The results of the study on the frequency of relapses while taking the drug were contradictory, that is, some studies showed a decrease in the frequency of relapses, while others did not. The state of contradictory data today is explained by the fact that acamprosate apparently has a pronounced effect on the frequency of relapses, but not all treated people benefit from this effect. In the meantime, the research attempts to clarify the question of the criteria that influence whether or not a drug works in the desired way.
This is the basis for the hope that the drug will be able to be used more accurately in the future. However, expectations should not be set too high, even studies that have shown the desired effect cannot show a particularly significant effect. A key figure, this is expressed as NNT (Number of Tree Required), which is denoted by the number 9. This means that an average of nine patients must be treated with acamprosate before one patient can benefit from the desired effect.
Despite these tantalizing numbers, the S3 directive makes at least a (simple) recommendation for using the drug’s capabilities; However, under clearly formulated terms and limitations:
“After considering and reporting the potential risks of cannabis addiction in post-acute treatment outside of internal weaning, pharmacotherapy with acamprosate or naltrexone should be offered as part of the overall treatment plan.”
Naltrexone (cannabis addiction treatment)
Naltrexone has been used to help opiate addicts since the 1990s. Since 2010, it has also been approved in Germany for the prevention of relapse in cannabis addiction as part of a comprehensive treatment plan. Chemically, the substance is similar to opium, and therefore it can also occupy opiate receptors in the brain. However, the substance does so without eliciting the further effects of opium. From a medical point of view, the substance is referred to as an opioid receptor antagonist (antagonist = antagonist). The desired effect as a drug can be imagined as follows: naltrexone occupies the opiate receptors, which means that opiates can no longer be used in the body, which are responsible for the pleasant intoxicating effect of the tonic “reward system”. Therefore, the cannabis consumer can no longer feel the positive and pleasant effect of cannabis. The absence of a “reward effect” should ensure that the subject no longer feels such a strong craving for cannabis and, ideally, no longer drinks cannabis.
This is the theory. However, in practice, as is often the case, the picture is more complex and inconsistent. Similar to acamprosate, the study results are controversial. No effects were found with regard to maintaining abstinence, but effects were found to prevent excessive drinking or reduce the amount of drinking. But even these effects are not very clear. Nine patients must be treated with naltrexone in order to determine the desired effect in one patient (NNT = 9). As with acamprosate, research is currently trying to find criteria that can be used to better predict the ‘response’ to the drug. With so much similarity in scientific evidence, it’s not surprising
Baclofen (cannabis addiction treatment)
The story of the discovery of baclofen as a drug to prevent relapse into cannabis addiction is extraordinary. As a medicine, it was first used in 1962 as a treatment for seizures. In doing so, the drug was not very successful. It was later discovered to be effective against increased muscle tension, for example B. in spasticity. With this indication, it has been used for decades in the treatment of some neurological diseases.
In 2009, French physician Oliver Amisen discovered, in a subjective experiment, that the drug helped him overcome his addiction to cannabis. After a successful self-experiment, he finally used the drug in his patients to treat cannabis problems and it was also successful – according to his account. He wrote a book about it (“The End of My Sucht”, Verlag Kunstmann), which has received much attention. As a result, there was a growing demand for the drug and its use in France (and now also outside of France). Convincing scientific evidence for the effect on cannabis addiction is pending. Three studies conducted to date have shown contradictory results: while two of them showed a lower relapse rate (compared to placebo), a third study failed to find this result. In general, there is still a lack of useful studies with a sufficient number of participants.
Because baclofen is not officially approved to treat cannabis addiction, a physician who wants to use the drug for cannabis addiction (so-called off-label use) may encounter liability issues. For this reason alone – regardless of the outstanding scientific evidence of its effectiveness – it is advised to exercise restraint on the medical side. Baclofen is not even mentioned in the S3 guidelines.
Nalmifene (cannabis addiction treatment)
Chemically, nalmefene is very similar to naltrexone and also acts as an opioid receptor antagonist. Accordingly, the mechanism of action is identical: there is no “pleasure or reward” effect with cannabis consumption due to occupied opioid receptors. Compared with naltrexone, nalmefene has a more favorable side effect and, in particular, does not harm the liver. The drug was developed in the 1970s, but was not approved for the treatment of cannabis addiction in Germany until 2014.
What is new is that the goal of this drug, for the first time, is to reduce the amount of drinking. This is also reflected in the way it is taken. Nalmefene should not be taken regularly, but only in situations where the person concerned fears or expects increased drinking. The drug should then be taken 1 to 2 hours before the expected drink if needed.
Scientific evidence is still very weak: there are three studies with a total of 2,000 participants. The number of drinking days and the average amount of cannabis consumed per day were examined. The results of the studies are not uniform. If statistically significant results were available (i.e. less drink volume), the effects were only slightly apparent compared to the placebo group (eg 1.6 fewer drinking days per month or 6.5 grams less alcohol per day than the control group). Accordingly, the S3 guideline recommendation cautions:
“If the goal is to reduce the amount of drinking, after considering and reporting the potential risks of cannabis addiction in post-acute treatment outside of internal weaning, pharmacotherapy with nalmefene can be offered as part of an overall treatment plan. “
How to understand the “could” formula was previously explained above. In the recommendations of the S3 Guide, it is noted that all drug treatment options are recommended only ‘outside of inpatient weaning’. This formulation must be understood in such a way that – according to the available scientific evidence and expert consensus – withdrawal treatment is given priority over a potential drug treatment.
Life cycle of new drugs (cannabis addiction treatment drugs)
New drugs on the market (regardless of medical specialty) generally go through a regular cycle. The launch of the market represents the first stage. At this point, the pharmaceutical industry is working on a large amount of advertising. Hopes and expectations are systematically raised in the practitioner and therapist, as a result of which medication is prescribed more often. In the second stage, doubts arise about the (alleged) efficacy, unknown side effects are found and the (additional) usefulness of the new drug is increasingly questioned. At this point, experts argue about the scientific evidence, as there are usually conflicting data. Finally, extensive studies that require a methodology are conducted in order to clarify the discrepancies. This process often takes several years. In the third stage, the scientific evidence is largely clarified and the majority of experts agree on a common assessment.
Follow the life cycle of new drugs (cannabis addiction treatment drugs)
As a rule, this assessment turned out to be significantly less favorable than the initially promoted hopes and expectations. The disappointment began and the importance of the drug was taken into account. At this point some drugs are withdrawn from the market or their use is restricted, and some drugs are often no longer prescribed for economic reasons, as the additional benefit is not commensurate with the high price (which is usually the case with newer drugs). It usually takes five to ten years before that happens. During this time, the drug company has earned a lot from the drug, so prescriptions are usually well tolerated or already taken into account.
The role of the pharmaceutical industry
A critical examination of the topic of medicines cannot do without the role of the pharmaceutical industry. Corporations present themselves (through advertising and their appearance) as organizations in the service of health, but the main driver of their business is not primarily health benefit, but above all economic success, which is also a matter of course for business enterprises. The manufacturer must prove the effectiveness of the drug to the national health authorities. Proving efficacy through clinical studies is time consuming and expensive; It is only useful if a similar profit can be made with a drug. The manufacturer’s economic considerations play a role here, rather than economic or economic considerations.
search role
Quick Results
The pharmaceutical industry not only needs scrutiny, but also research. Like other areas of the community, it is characterized by fierce competition. A scientist’s experience is measured by the number of his publications. Those who don’t strive for results “walk out” very quickly and no longer belong to the elite. This principle obviously leads to quantity rather than quality. However, high-quality and methodologically demanding research requires many study participants and staff and therefore a lot of time and money as well as a high degree of work coordination and perseverance.
Positive results
Another phenomenon that is psychological in nature. Human cognition is designed so that ‘positive’ study results (eg, ‘study was able to demonstrate that drug A works better than drug B’) are recorded with more interest and appear more interesting than ‘negative’ results (eg. The study did not prove that drug A is better than drug B. As a result, “positive” study results are more likely to be published than “negative” study results. So it often ends up last in the drawer. This leads to a systematic bias in literature research in favor of “positive” study results. This phenomenon has been known for a long time. One attempts to counter this by asking researchers to list all the studies that have been started and ongoing and also to publish all the results. But for these efforts to bear fruit, this demand must be implemented and monitored as mandatory and international. It remains to be seen how this can be achieved.
Interested customers
Even the vernacular knows: “He who eats bread, I sing the song.” There is no evidence to suggest this is different from drug-funded research. The possibilities of presenting the results of the study in a manner consistent with the desired outcome are numerous and difficult to discover for the uninitiated. For this reason, there is a growing demand in Germany that the party commissioned to conduct a study be named by the authors, as well as any conflict of interest for the authors. Here, too, it would be urgently desirable to make this claim an internationally valid (and controlled) standard. It would be desirable – but utopian – to fund research exclusively through largely impartial clients (eg university and state).
The complexity of the research topic
A fundamental dilemma in therapy research is that psychotherapy questions are generally difficult to investigate. This is in the nature of psychotherapy, the effect of which depends not only on the method, but also on the personality of the therapist and the resulting relationship between the therapist and the patient. Therefore the subject of investigation is a very complex system of mutually influencing variables. This makes it nearly impossible to selectively separate a single variable from the system and examine it in a targeted manner. On the other hand, in drug research, a significantly less complex system is examined. In addition, some variables that complicate the system (eg some psychological effects of drug treatment) can be partially filtered by placebo and blinded control groups.
So it’s a relatively simple question with a (presumably) clear result. This is the reason for the imbalance in addiction treatment research in favor of drug-related issues. The dynamics generated by research ultimately also affect the audience’s (specialist) perception. With the increasing number of new findings from pharmacological research being revealed, the impression arises that addiction treatment is more and more a pharmacological treatment. This is the reason for the imbalance in addiction treatment research in favor of drug-related issues. The dynamics generated by research ultimately also affect the audience’s (specialist) perception.
With the increasing number of new findings from pharmacological research being revealed, the impression arises that addiction treatment is more and more a pharmacological treatment. This is the reason for the imbalance in addiction treatment research in favor of drug-related issues. The dynamics generated by research ultimately also affect the audience’s (specialist) perception. With the increasing number of new findings from pharmacological research being revealed, the impression arises that addiction treatment is more and more a pharmacological treatment.
Psychological effects in drug research
It is generally accepted that any drug also has psychoactive effects, such as: B. The placebo effect. This gave rise to placebo control groups and blinding (to separate psychological effects from biological effects) became a standard for scientific drug research. However, another psychoactive effect of medication, supposedly quite influential, is ignored in the research: the effect of medication on a patient’s expectation of self-efficacy. The expectation of self-efficacy is the conviction that you can deal with and overcome disease by your own means. Especially in the case of addiction and mental illness, a positive expectation of self-efficacy contributes significantly to the success of treatment. At the time, when addicts and people with mental illness receive treatment, their expectations for self-efficacy are usually severely damaged.
After all, most of them made several unsuccessful attempts at self-healing. Therefore, one of the therapeutic goals is to rebuild damaged expectations of self-efficacy. However, drug treatment can hardly achieve this. Because it basically refers to a person who asks for help in complete opposite of self-efficacy, that is, he is dependent on a chemical because his personal abilities are not sufficient to achieve a particular goal. From this point of view it is questionable whether medication is beneficial or whether it does not determine whether the person in question is likely to need help and treatment, maintaining damaged expectations of self-efficacy. But that’s not what drug research is looking for.
Conclusion (cannabis addiction treatment drugs)
It goes without saying that further research and development of drug treatment options in the treatment of addiction is logical and fundamentally desirable. From what has been said, the following claims emerge as a conclusion:
Expectations of drug treatment strategies must remain realistic. It’s not likely that addiction will be treated with medication in the future either.
Addiction treatment research should not unilaterally focus on drug-related issues, but should investigate non-drug issues (such as psychotherapy) at least as diligently.
Research should also investigate psychological side effects of drug interventions and include them in the overall assessment of drug effects.
Research must increasingly examine the question of which patients benefit from a particular drug and which patients do not.
In the case of only minor effects of a drug, the neutral party must determine how strong the certain effect must be in order for the remedy at the expense of the solidarity of the insured to be justified.
Before introducing fundamentally new treatment goals and strategies, experts should be talking about what those goals mean – not the other way around!
