Drug and alcohol treatment has traditionally primarily followed the 12-Step model of complete abstinence in order to maintain a successful recovery from a substance abuse disorder.
Relapse rates can be high at around 40-60 percent, mirroring those of other chronic diseases, such as diabetes, asthma, and hypertension, as reported by the National Institute on Drug Abuse (NIDA). Addiction is defined as a chronic and relapsing brain disease, and relapse is considered a natural part of recovery. Treatment, therefore, seeks to lessen the severity and duration of relapse.
Several medications are now being explored and used effectively during substance abuse treatment that may help to prevent relapse, or a return to substance abuse. These medications may be used during recovery as an alternative to complete abstinence in some cases, or during a medical detox protocol as a way to safely and successfully flush toxins from the body. Cravings and withdrawal symptoms may be blunted by the use of certain medications, and many of these pharmaceuticals block drugs or alcohol from creating the same high or desired pleasant feelings. These medications may be used short-term during detox or as part of a long-term maintenance therapy. Medications are not a “magic bullet” or cure-all for addiction, but when used during substance abuse treatment, they may increase the odds of a healthy and productive recovery.
Alcohol Use Disorder
The National Survey on Drug Use and Health (NSDUH) reported that as many as 18 million people in America over the age of 12 needed treatment for an alcohol use disorder in 2013. Alcohol is generally socially acceptable and easy to obtain. While drinking alcohol does not constitute a problem in and of itself, chronic episodes of heavy, or binge, drinking may lead to the development of a tolerance to alcohol. Once a tolerance has been established, it will take more each time in order to feel intoxicated.
Alcohol makes chemical changes in the brain, affecting the reward and motivation pathways. By stimulating the production of the neurotransmitter dopamine, which is responsible for feelings of pleasure, drinking alcohol makes you feel good initially. Over time, chronic drinking may lead to the brain becoming dependent on the chemical stimulation of dopamine and cease to produce it naturally, encouraging the further consumption of alcohol, and cravings for alcohol, in order to feel good or happy. This dependence may evolve into an alcohol use disorder when alcohol becomes the focal point of life and is continuously abused despite negative social, emotional, and physical consequences. Those suffering from an alcohol use disorder will likely also battle uncomfortable and even life-threatening withdrawal symptoms when alcohol is removed.
It is not recommended to stop drinking cold turkey if you suffer from an alcohol use disorder. Rather, a weaning-off period may be instituted instead. Medications are also used during alcohol detox to manage cravings and withdrawal symptoms.
Medications During Alcohol Treatment
The U.S. Food and Drug Administration, or FDA, currently approves four medications for the treatment of an alcohol use disorder as reported in Psychiatry:
- Disulfiram (Antabuse)
- Naltrexone (ReVia)
- Acamprosate (Campral)
- Once-a-month injected naltrexone (Vivitrol)
Disulfiram has been used as an alcohol aversion medication for some time. Staying in the system for a week or two, disulfiram causes negative side effects, such as nausea, vomiting, and headaches when it interacts with alcohol. It is intended, therefore, to discourage alcoholics from returning to drinking alcohol. Disulfiram may have unintended or potentially dangerous health risks in the event of an overdose, however. Low blood pressure, shortness of breath, chest pain, and even death may occur. Disulfiram may work best to discourage impulsive drinking, although alcoholics may stop taking the medication intentionally before drinking, thereby reducing its long-term effectiveness in preventing relapse. Disulfiram is believed to have the highest success rates when social and family support networks are highly involved and vigilant in ensuring the medication is taken regularly.
Conversely, naltrexone is not an aversion drug, but instead functions as an opioid antagonist, blocking opioid receptor sites from receiving the endorphins or neurotransmitters stimulated by alcohol, thereby reducing the reward.Naltrexone, therefore, diminishes alcohol cravings. It does not produce negative side effects when taken in conjunction with alcohol and consequently will not necessarily promote an abstinent lifestyle independently. It may, however, decrease the amount of alcohol consumed since it does keep drinkers from achieving the euphoric feelings alcohol produces without the medication.
The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that naltrexone is effective in reducing relapses related to episodes of heavy drinking as well as decreasing the quantity and frequency of those who drink. ReVia is an oral medication taken in pill form once daily, and like disulfiram, it needs to be willfully taken in order to be effective. Vivitrol is injected once a month and may be more effective for those without the motivation or external support to continue taking naltrexone on their own. Naltrexone is meant to be used in conjunction with a treatment program that includes behavioral therapies, encouraging alcoholics to not strictly rely on the medication to manage their recovery. Naltrexone may cause headaches, nausea, stomach pain, fatigue, and, in some cases, liver damage. It should not be used within two weeks of taking a narcotic drug.
Gamma-aminobutyric acid (GABA) is an inhibitory neurotransmitter stimulated by alcohol consumption. Acamprosate is one of the newer medications approved for the treatment of an alcohol use disorder, and it functions by inhibiting GABA transmission, thereby producing a calming and relaxing effect on the brain and reducing alcohol cravings. As with naltrexone, acamprosate is not an aversion medication and does not produce negative results when mixed with alcohol. Acamprosate is also an oral medication usually taken up to three times a day and requires compliance in order to be effective.
Combined with psychotherapy, acamprosate does seem to indicate positive results in the reduction of heavy drinking episodes and may improve quality of life. Side effects of acamprosate may include headache, diarrhea, and some memory impairment as well as potential kidney problems. When used in combination with naltrexone and behavioral therapies, acamprosate may improve alcohol treatment retention rates and promote long-term recovery.
Other medications are also used during the treatment of an alcohol use disorder, although they may not be specifically intended for use on alcohol dependence. Topiramate (Topamax) is an anti-seizure medication generally used to treat epilepsy, although it may help to control impulsivity and alcohol dependence. Since alcohol directly affects pleasure and the reward circuitry in the brain, antidepressant, anti-anxiety, or mood stabilizing medications may be introduced during alcohol treatment as well in order to combat withdrawal symptoms, helping to maintain healthy balance in the brain.
Medical Management of Opioid Dependency
Just as alcohol makes chemical changes in the brain and disrupts the natural reward pathways, so does opioid abuse. Opioid drugs include street drugs like heroin as well as prescription narcotics, including Vicodin, OxyContin, Percocet, and morphine. The abuse of prescription medications has reached epidemic proportions in the United States, and the Centers for Disease Control and Prevention (CDC) lists drug overdose as the leading cause of injury death in America in 2012, with 51.8 percent of overdose deaths involving pharmaceuticals and 71.3 percent of fatal pharmaceutical overdoses involving opioid analgesics in 2013.
These drugs are highly addictive, and withdrawal symptoms may be both physically and emotionally uncomfortable. Several medications are approved both to help manage withdrawal symptoms and cravings, precipitate detox, and as a part of long-term maintenance therapy, including:
- Buprenorphine (Subutex)
- Buprenorphine and naloxone (Suboxone)
Harm reduction is a term often heard when discussing opioid maintenance therapy. While widely accepted abroad, it is still largely controversial in the United States. Harm reduction is a public health policy that accepts drug use and abuse as standard and seeks to reduce the negative consequences instead of calling for outright and total abstinence. For example, harm reduction seeks to minimize criminal activity and the spread of infectious diseases by providing needle exchange programs and community outreach centers.
One facet of harm reduction is opioid maintenance therapy that provides opioid medications such as methadone in federally funded clinics in order to prevent the use of more potent street drugs like heroin. Methadone is a synthetic, long-acting opioid taken orally. It acts on opioid receptors in much the same way as other opioids, although with lesser effect, producing less of a high. Methadone is used to combat cravings and manage withdrawal symptoms, although is more widely used for long-term maintenance therapy.
The New England Journal of Medicine published a study showing a 50 percent decrease in heroin overdose deaths between 1995 and 2009, with the increased availability of opioid maintenance medications including methadone. Individuals substituting methadone for heroin were less likely to engage in criminal activity or contract blood-borne diseases and more likely to function within society. Methadone is still an opioid drug, however, and it is not without abuse or addiction potential itself. Psychosocial support is imperative for a successful recovery with the use of methadone.
The Drug Abuse Treatment Act (DATA) of 2000 precipitated the approval of buprenorphine by the FDA for opioid dependency treatment. Suboxone and Subutex were the first narcotic medications under DATA to be prescribed in doctors’ offices. Buprenorphine is a partial opioid agonist that binds to the opioid receptor sites without producing euphoria. This allows it to manage cravings and stave off withdrawal symptoms, making Subutex a viable medication for use during opioid detox and the early stages of withdrawal. Buprenorphine is usually dispensed in a sublingual tablet or strip that is dissolved in the mouth. While still an opioid agonist with the potential for abuse, buprenorphine has a ceiling effect wherein after a certain amount is taken, a plateau is reached preventing any further effects.
Suboxone combines both buprenorphine and the opioid antagonist naloxone that blocks opioid receptor sites, deterring abuse of other opioids. When you take another opioid while on Suboxone, for instance, withdrawal symptoms will start and no high is established. Naloxone on its own is used to medically reverse the effects of an overdose. When used for treatment of an opioid dependency, it should only be administered after all other opioids are purged completely from the body. Suboxone is used more often after detox and during the maintenance phase of recovery.
Naltrexone is used for opioid dependency treatment much in the manner it is used for the treatment of alcohol dependency. Sometimes naltrexone is used in a more targeted approach, or on days the user may be at a higher risk of abusing drugs or alcohol; however, this shortcut is not usually recommended or proven effective. Naltrexone may also be administered under general anesthesia in a “rapid detox” procedure, although this is also not frequently endorsed or proven to be effective long-term, either. In the past, other medications such as levo-alpha acetylmethadol, or LAAM, was utilized as an alternative to methadone during opioid replacement therapy as it required less frequent dosing, although the name-brand LAAM medication Orlaam has subsequently been removed from the US market due to the potential for life-threatening ventricular rhythm disorders.
While there are no shortcuts to recovery, medications can ease the transition and even increase the success rates when used as a part of a treatment model in tandem with therapies, counseling, and support groups. Addiction has both physical and emotional components that need to be addressed during substance abuse treatment. Medications do not stop addiction, but rather are beneficial as a part of a comprehensive treatment.
Substance abuse and addiction cost society upwards of $524 billion a year in crime, lost productivity, and health care costs, according to NIDA, and by preventing relapse and criminal drug-seeking behavior, medications may help reduce these costs. Many 12-Step programs insist on complete abstinence as a requirement of recovery, although some groups and programs are modifying this stance to allow for the inclusion of certain pharmaceuticals, although most do not accept the use of any mood-altering substances. The long-term goal of most treatment models is reintegration with family, community, and society as a whole, and both maintenance therapies and abstinence models have their subsequent roles in recovery.
A detailed treatment plan with regular evaluations and assessments is a necessary part of recovery as well. Medical professionals can help you decide which treatment method is best for your unique circumstances and will provide you with the highest rate of success and retention during recovery.
Some medications will be more effective on certain people than others due to genetic or environmental factors. Many of these addiction treatment medications are fairly new and underutilized. Only around 34.4 percent of substance abusers actively involved in programs actually receive medication-assisted therapies (MATs), according to the New England Journal of Medicine. Sometimes medications used in drug or alcohol treatment will need to be combined in order to achieve the best results.
Additionally, the National Alliance on Mental Illnesses (NAMI) estimates that half of all drug abusers and one-third of all alcohol abusers also suffer from mental illness. The diagnosis of a mental illness may require medications to manage symptoms, and these medications will need to be closely monitored in someone also battling substance abuse. The occurrence of two disorders in the same individual at the same time is considered a dual diagnosis and the most successful treatment models provide comprehensive, evidence-based, integrated, and simultaneous care.
FRN treatment centers provide a continuum of care for substance use disorders, mental health disorders and dual diagnoses. Our treatment professionals work together to promote a long and healthy recovery.
Addiction is a treatable disease, and we are here to serve you and your loved ones. Call now to learn more.
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David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.