Pharmacological treatments for drug misuse and dependence

Introduction: Substance misuse disorder (DSM-5) remains a major health challenge. Harm reduction is the initial treatment goal, by reducing or eliminating non-prescribed drug use. Eventual abstinence is the ultimate harm reduction goal. However the scope for evidence-based pharmacological interventions remains limited. Areas covered: The paper takes a pragmatic clinical approach to existing and developing pharmacotherapies for substance misuse. Dependence may be characterised as a cycle with three stages: binge/intoxication, withdrawal/negative affect and preoccupation/anticipation (craving). Each of these stages may be the focus of pharmacotherapeutic intervention, and current literature is discussed which is of relevance to the practising clinician. Dependence on opiates, stimulants, cannabis and prescribed medications including benzodiazepines and the current treatments are addressed. Expert opinion: Possible pharmacotherapies of the future include anti-craving medications, which are still incompletely understood. Other developments include ultra-long-acting formulations, some of which have already been produced and are being studied or are in early clinical practice. A completely new line of investigation has been drug 'vaccines', whereby the body is stimulated to produce antibodies to, for example, cocaine and nicotine. Despite a number of evidence-based strategies for the treatment of substance misuse disorder, the range of licensed pharmacological treatment choices nevertheless remains narrow.