The State of the Art in Treatment, Today and Tomorrow

I n drug abuse, as in other medical areas, clinicians strive to perfect the current state of the therapeutic art, while researchers prepare the ground for an improved future state of the art. This issue of Addiction Science & Clinical Practice offers examples of both projects. There is a comprehensive survey of principles and best clinical practices in one vast and vexed area of treatment, and two accounts of work being done to develop potentially powerful new tools. Individuals with histories of substance abuse and addiction have higher rates of current and chronic pain than the general population. For many, no analgesic modality short of opioids will yield adequate relief. The clinician faces a dilemma: the obligation to alleviate suffering versus the potential for precipitating relapse. Dr. Seddon Savage and coauthors lay out clear principles to structure decision making in these cases. They note, for example, that brief use of opioids for acute pain seldom affects the course of recovery from addiction. They also give guidelines for applying their principles in everyday practice. Readers will find, for example, a list of items to consider in making a differential diagnosis of possible reasons for opioid misuse, tips for spotting diversion, and advice on choosing an appropriate opioid in various situations. Dr. Kyle Kampman reports on efforts to identify currently available medications that can aid recovery from stimulant addiction. To date, several have shown early promise. Should any prove valuble in large-scale clinical trials, clinicians treating this patient population could have badly needed new tools in the relatively near future. A future article in our journal will discuss parallel efforts to create brand new compounds for stimulant abuse. Dr. Marsha Linehan's dialectical behavioral therapy (DBT) helps many patients with borderline personality disorder who also abuse drugs. As further developed by Drs. Linehan and Linda Dimeff, it may also prove useful for a broader segment of the addicted population. Advancing the state of therapeutic art is a multidimensional task, requiring consideration of many questions from many viewpoints. This issue's response panelists bring a diversity of ideas and experiences to bear on the themes raised by our authors. Readers may find particularly noteworthy the exchanges on when and how potential new medications for stimulant abuse might be integrated into treatment , and on total versus partial implementation of manualized therapies. We encourage readers who wish to respond to any article or panel to post …