November 26 , 2007

Drugs for Drugs: Medications to Treat Addictions
By John K. Smith, PhD, LCSW
For The Record
Vol. 19 No. 24 P. 21

Using medications to help treat substance abusers has its critics, but in many cases, they’ve been effective.

Roughly 8 million people in the United States currently meet the diagnostic criteria for alcohol dependence.1 Another 6 million or more meet the criteria for alcohol abuse.

Alcohol dependence is considered a major public health problem and is ranked as the fourth leading cause of disability.2 Additionally, illicit and prescription drug abuse and dependence are on the rise. The invention of newer and more potent opiate-based prescription medications for pain treatment, such as oxycodone (OxyContin) and hydrocodone (Vicodin), along with easier access to these medications via physicians and the Internet, has led to widespread abuse and addiction.3

The estimated annual cost of substance use disorders in the United States is $510 billion.4 Millions of people have suffered or are suffering from the ravages of drug abuse and addiction, and millions more have suffered by being in a relationship with someone abusing or addicted to substances.

Addiction treatment has evolved extensively during the last several years. The primary psychosocial treatment method involves a 12-step-based program structured around the principles of Alcoholics Anonymous (AA). Clients are taught the basic “steps” and principles of recovery and learn to live clean and sober. Participation in 12-step-based support groups is usually mandatory or highly encouraged.

However, newer methods have emerged in the treatment of substance abuse and addiction. The use of cognitive behavioral therapy, including skills training; motivational enhancement techniques, a stages of change model; and integrated treatment for clients with co-occurring disorders have been shown to increase positive outcomes in addiction treatment.5 While there is no “magic bullet” or cure for addiction, substance abuse treatment has been shown to be effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives such as no treatment or incarceration.3

Specialized medications to treat substance abuse and addiction have also been added to the arsenal of weapons for fighting this “disease” but are still controversial. Ironically, the biggest controversy comes from the people these medications are designed to treat. “Many of us in the 12-step community do not believe that a person is really clean and sober if they have to use drugs to get off of drugs,” says Danny F., a long-standing member of a local 12-step program. While AA and Narcotics Anonymous organizations formally support the use of prescription medications necessary to treat mental illness or other medical issues, many believe that the use of any medications, especially mood-altering medications, puts a member’s sobriety in question.5

Additionally, many newer medications are designed to be dispensed in primary care settings, such as doctors’ offices and clinics. While potentially offering access to more people and decreasing the stigma of addiction treatment, there has been reluctance on the part of many primary care physicians to prescribe these medications in spite of an increasing body of research that shows the effectiveness of such medications.6 Some healthcare providers, like some clients, question the value of using any drug to treat drug or alcohol addiction.7

Medications for Treating Alcohol Dependence and Abuse

Disulfiram (Antabuse)
One of the oldest medications used in the treatment of alcohol abuse and addiction is disulfiram. Designed to provide users with aversive and unpleasant effects when drinking alcohol, the medication works by preventing the breakdown of alcohol in the body, creating reactions ranging from flushing and nausea to, in some cases, death. The goal is alcohol avoidance based on the fear of experiencing these unpleasant effects. Unfortunately, there is no evidence that the use of disulfiram results in higher abstinence rates or longer periods of abstinence.4

Because of the potentially dangerous results and complications, this medication is not used with everyone attempting to stop drinking alcohol. Users must be educated about how to use the medication safely and must also be motivated to use it regularly. This medication can act as an additional support tool for those who are able to use it. Fear of the unpleasant side effects can help to give users time to “think before they drink.” For many, this extra time may help the user to avoid impulsive drinking. Unfortunately, research shows that many users stop the medication a few days before they plan to drink, suggesting that there is less of an impulsive reaction and more of a planned one. This relapse process is triggered by or will trigger intense cravings for alcohol.

Naltrexone (ReVia)
In 1994, naltrexone was approved by the FDA to treat alcohol dependence after the medication was shown to reduce the frequency of drinking and likelihood of relapse to heavy drinking.8 The drug is considered an opioid antagonist and acts by blocking the effects of opiate drugs and is also thought to reduce the behavioral response to alcohol. Several components of the alcohol drinking sequence are affected, including lowered cravings, decreased reinforcement of drinking, and increased headache and nausea that further reduce the quantity of intake.9

Numerous studies have shown the effectiveness of this medication in reducing drinking and preventing relapse.6 According to Said Jacob, MD, a psychiatrist and addictionologist practicing in Glendora, Calif., “I have been using naltrexone and related medications successfully for a long time. They really work to reduce the cravings for alcohol. I generally keep patients on it for six months to one year. I want patients to not rely totally on the medicine to not drink. They must be in some form of supportive therapy or recovery.” Jacob also says that this medication successfully reduces opiate cravings and use.

One problem with the use of naltrexone, as well as other medications, is compliance.4 Low motivation, avoidance of unpleasant side effects, cognitive impairments, and willful neglect are cited as primary reasons for medication noncompliance. To combat this problem, a new long-acting injectable form of naltrexone called Vivitrol has been developed. Clients receive a once-per-month injection of the medication rather than taking daily oral doses. Jacob reports that he is seeing good results with this form of the medication, and clinical trials have supported his observations. He cautions that it is still too early to determine the long-term effectiveness of this medication.

Acamprosate (Campral)
Another medication used for treating alcohol dependence is acamprosate. Like naltrexone, it is used to reduce alcohol cravings and prevent relapse. It is chemically different than naltrexone and has agonist effects at gamma-aminobutyric acid receptors and inhibitory effects at N-methyl-D-aspartate receptors.9 It can be used separately or in combination with naltrexone.

In a meta-analysis of all placebo-controlled trials of naltrexone or acamprosate for alcoholism treatment, there were significant effects on treatment retention and/or drinking outcomes. There did not seem to be any statistically significant difference in either drug’s efficacy in alcoholism.6 However, the authors state that there has been an absence of studies comparing the effects of these medications.

One recent randomized controlled trial, the COMBINE Study, examined the efficacy of acamprosate, naltrexone, and combined behavioral interventions (CBI).10 The researchers looked at each medication individually with or without CBI and combined with or without CBI. They reported that medical management with naltrexone, CBI, or both produced better outcomes, but acamprosate showed no evidence of efficacy with or without CBI. Also, there was no evidence that combining the two medications produced better results than the naltrexone or CBI alone. Thus, more research is needed concerning the overall effectiveness of acamprosate for treating alcohol dependence.

Medications for Treating Opiate Dependence and Abuse
Opiate addiction often comes in two forms: addiction to illicit drugs such as heroin and addiction to prescription drugs—sometimes obtained illicitly—containing an opiate, primarily used to treat acute or chronic pain. Vicodin and OxyContin are the most well-known of these drugs. Many people become addicted to these prescription medications due to long-term use and dosage increases due to tolerance without ever abusing them.

At some point, many opiate users become physically dependent and continue to use or abuse the drug to avoid withdrawal symptoms. While not life-threatening, withdrawal from opiates is unpleasant. Usually, the symptoms are flulike and can be moderate to severe. Some people attempt to stop using opiates cold turkey without medication or support. While some are successful, many relapse because of intense drug cravings or intolerance of the withdrawal symptoms. Paul Koo, PharmD, a pharmacist at Doctor’s Hospital of West Covina, Calif., describes the withdrawal from heroin and other opiates “... like falling off a cliff.”

Medications can be used to ameliorate withdrawal and replace or substitute for illicit drugs. While some have been used for many years, new medications have been developed that offer promising results.

Methadone
Used extensively for the treatment of opiate withdrawal and replacement since the mid-1960s, methadone has helped thousands of opiate addicts stop using opiates altogether or replace their illicit drug use and corresponding lifestyle and behavior with a return to more normal functioning.

While methadone can be used to ameliorate withdrawal symptoms in early detoxification, it is most known for its use in long-term maintenance. It is estimated that approximately 179,000 individuals are currently in a methadone maintenance program in the United States.4

The usual treatment course involves daily visits to a licensed clinic to receive a single dose of methadone to offset cravings and withdrawal symptoms. Theoretically, clients also will receive psychosocial support services, including drug testing, to verify abstinence from other drugs. While this is the desired approach, it has not been the practice in many programs that offer little more than a steady supply of oral methadone.4

One positive effect of methadone maintenance vs. the continued use of heroin or other opiates is that, by receiving a regular dose of medication, the client is not forced to engage in illegal or undesirable behaviors to secure the drug. Unfortunately, if clients are not monitored or receiving psychosocial support, they may continue to engage in drug abuse and the associated lifestyle.

Levo-alpha Acetyl Methadol (LAAM)
An alternative to methadone is a medication known as LAAM, which is also primarily used as a replacement therapy for opiate drugs. LAAM is sometimes preferred to methadone because it requires less-frequent dosing, allowing for fewer clinic visits and expanded integration into work and other rehabilitative activities.9 LAAM treatment outcomes are comparable to methadone with respect to reduction of opioid use, although retention rates are higher for clients treated with methadone.9 Longer LAAM treatments are associated with better outcomes.

Buprenorphine
Relatively new medications—two forms of buprenorphine—were approved in 2002 for office-based treatment of opioid abuse and addiction. Suboxone and Subutex are used for detoxification and maintenance treatment. These medications come as sublingual tablets and can be self-administered.

Outcomes appear to be similar to methadone, and some studies have produced promising results on the effectiveness.11 One advantage is that the client does not need to visit a registered clinic several times per week, increasing access and convenience. A disadvantage is that it makes it easier for the client to avoid or discount the importance of psychosocial rehabilitation or support. Physicians wishing to prescribe this medication must meet special training criteria and agree to treat no more than 30 patients at any time in their individual practice.

Subjectively, many clients being treated with buprenorphine report better results and compliance even with previous failures on methadone or other treatments. Koo adds, “Buprenorphine eases the fall, and for some, it seems to stop the fall altogether.”

The Search for a “Cure”
The use of medications in the treatment of substance abuse and dependence has become a new priority as scientists, physicians, and treatment providers look for a “magic bullet” that will stop or prevent the cycle of addiction. Current research and clinical trials are being conducted on numerous promising medications and treatments.

One area of resistance to the use of medications for substance abuse treatment is the ongoing debate regarding abstinence vs. harm reduction. Many in the substance abuse treatment field and the 12-step support community believe that total abstinence from substances (including psychotropic medications) is a necessity for a person to be truly clean and sober. For many, especially those with co-occurring disorders, abstinence is a goal but not an absolute.5 Using medications to reduce cravings, avoid relapse, or decrease the frequency and effects of drug or alcohol use (harm reduction) can offer hope and reduce the emotional and social costs of substance abuse and addiction.

— John K. Smith, PhD, LCSW, is a licensed psychotherapist with more than 25 years of experience in the mental health and chemical dependency fields and is program administrator for the Dual Diagnosis Day Treatment Program at Doctor’s Hospital in West Covina, Calif.

References
1. Grant BF, Dawson DA, Stinson FS, et al. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 2001-2002. Drug Alcohol Depend. 2004:74(3):223-234.

2. Murray CJL, Lopez AD (eds.) Global Burden of Disease. Cambridge, Mass..: Harvard University Press, 1996.

3. National Institute on Drug Abuse. Epidemiological trends in drug abuse - Advance report, December 2001. Community Epidemiological Work Group, 2001.

4. Doweiko HE. Concepts of Chemical Dependency, 5th ed., Pacific Grove, Calif: Brooks-Cole, 2002.s

5. Smith JK. Co-occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide. Lanham, MD: Jason Aronson/Rowman and Littlefield, 2007.

6. Kranzler HR, Van Kirk J. Efficacy of naltrexone and acamprosate for alcoholism treatment: A meta-analysis. Alcohol Clin Exp Res. 2001;25(9):1335-1341.

7. Freed PE, York LN. Naltrexone: A controversial therapy for alcohol dependence. J Psych Nurs Ment Health Serv. 1997;35(7):24-28.

8. Garbutt JC, Kranzler HR, O’Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: A randomized controlled trial. JAMA, 2005;293(13):1617-1625.

9. Keltner NL, Folks DG. Psychotropic Drugs, 4th ed. St. Louis, Mo.: Elsevier.

10. Anton RF, O’Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA. 2006;295(17):2003-2017.

11. Amass L, Bickel WK, Higgins ST. A preliminary investigation of outcome following gradual or rapid buprenorphine detoxification. J Addict Dis, 1994:13(3):33-45.