Drugs for Drugs — Medications to Treat Addictions
Using medications to help treat substance abusers has its critics, but in many cases, they’ve been effective. Know what’s available because these drugs are here to stay.
Roughly 8 million people in the United States currently meet the diagnostic criteria for alcohol dependence (Grant, Dawson, Stinson, & Chou, 2004). 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 (Murray & Lopez, 1996). Additionally, illicit and prescription drug abuse and dependence is on the rise. The creation 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, according to the National Institute on Drug Abuse (NIDA) (2001).
The estimated annual cost of substance use disorders in the United States is $510 billion (Doweiko, 2002). Millions of people have suffered or are suffering from the ravages of drug abuse and addiction. 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 (Smith, 2007). While there is no “magic bullet” or cure for addiction, substance abuse treatment has been shown effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives such as no treatment or incarceration (NIDA, 2001).
Specialized medications to treat substance abuse and addiction have also been added to the arsenal of weapons for fighting this “disease.” While not a new concept, the use of medications to treat substance abuse and addiction has potential but is 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 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 (Smith, 2007).
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. This is in spite of an increasing body of research that shows the effectiveness of such medications (Kranzler & Van Kirk, 2001). Some healthcare providers, like some clients, question the value of using any drug to treat drug or alcohol addiction (Freed & York, 1997).
To better understand how medications are used in the treatment of substance abuse and addiction, this article will review the most prominent medications on the market.
Medications for Treating Alcohol Dependence and Abuse
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.
Numerous studies have shown the effectiveness of this medication in reducing drinking and preventing relapse (Kranzler & Van Kirk, 2001). According to Said Jacob, MD, a psychiatrist and addictionologist practicing in Glendora, CA, “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 (Doweiko, 2002). Low motivation, avoidance of unpleasant side effects, cognitive impairments, and willful neglect are cited as primary reasons for noncompliance. To combat the problem of medication noncompliance, 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.
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 between the two drugs in these areas (Kranzler & Van Kirk, 2001). 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) (Anton et al., 2006). 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
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 flu-like 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, CA, 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.
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 in a methadone maintenance program in the United States (Doweiko, 2002).
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 (Doweiko, 2002).
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)
Outcomes appear to be similar to methadone, and some studies have produced promising results on the effectiveness (Amass, Bickel, Higgins, & Hughes, 1994). 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”
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 (Smith, 2007). 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 the program administrator for the Dual Diagnosis Day Treatment Program at Doctor’s Hospital of West Covina, CA. He is also a professor of alcohol and drug counseling at Mt. San Antonio College in Walnut, CA, and the author of the recently published book Co-occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide.
Anton, R.F., O’Malley, S.S., Ciraulo, D.A., Cisler, R.A., Couper, D., Donovan, D.M., et al. (2006). Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. The Journal of the American Medical Association, 295(17), 2003-2017.
Doweiko, H.E. (2002). Concepts of chemical dependency, 5th ed., Pacific Grove, CA: Brooks-Cole.
Freed, P.E. & York, L.N. (1997). Naltrexone: A controversial therapy for alcohol dependence. Journal of Psychosocial Nursing and Mental Health Services, 35(7), 24-28.
Garbutt, J.C., Kranzler, H.R., O’Malley, S.S., Gastfriend, D.R., Pettinati, H.M., Silverman, B.L., et al. (2005). Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: A randomized controlled trial. The Journal of the American Medical Association, 293(13), 1617-1625.
Grant, B.F., Dawson, D.A., Stinson, F.S., Chou, S.P., Dufour, M.C., Pickering, R.P. (2004). The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 2001-2002. Drug and Alcohol Dependence, 74(3), 223-234.
Keltner, N.L., and Folks, D.G. (2005). Psychotropic drugs, 4th ed. St. Louis, MO: Elsevier.
Kranzler, H.R., Van Kirk, J. (2001). Efficacy of naltrexone and acamprosate for alcoholism treatment: A meta-analysis. Alcoholism, Clinical and Experimental Research, 25(9), 1335-1341.
Murray, C.J.L., Lopez, A.D. (Eds.) (1996). Global burden of disease. Cambridge, MA.: Harvard University Press.
National Institute on Drug Abuse. (2001). Epidemiological trends in drug abuse - Advance report, December 2001. Community Epidemiological Work Group.
Smith, J.K. (2007). Co-occurring substance abuse and mental disorders: A practitioner’s guide. Lanham, MD: Jason Aronson/Rowman and Littlefield.