Medications in Addiction TreatmentPenelope P. Ziegler, M.D.Medical DirectorVirginia Health Practitioners’ Monitoring Program

Pharmacotherapy for Addiction

Medically managed withdrawal (detoxification)- ACUTE

Management of co-occurring psychiatric, medical disorders- ACUTE and/or CONTINUING

Maintenance of recovery- CONTINUING

Pharmacologic Interventions for Maintenance of Recovery

Agonist therapies Antagonist therapies Anti-craving therapies Immunological approaches Aversive therapies Medications to treat co-occurring

psychiatric or medical disorders

Agonist Therapy Basic concept: replace drug of addiction with

safer alternative that activates same receptor Examples:

Opioid agonist- methadone Opioid partial agonist- buprenorphine, others Nicotine agonist- nicotine replacement Nicotine partial agonist- varenicline

Methadone

Full agonist at the mu receptor Can be used for detoxification

Rapid (3-5 days) Prolonged (1-6 months or longer)

Most often used for maintenance Administered in federally licensed clinics

under careful monitoring Not-for-profit community-based clinics Clinics associated with teaching and research For-profit private clinics

Methadone: Advantages Improved outcomes

Methadone maintenance treatment has dramatically better outcomes than drug-free treatment, including detox, short- or long-term residential programs or outpatient care

Persons in methadone treatment are less likely to experience common complications of addiction Criminal behavior Infectious disease Drug-related violence

Comprehensive treatment approach Clinics provide and require variety of psychosocial

interventions and therapies Particularly useful for persons who need “life training”

Methadone: Disadvantages

Continued use of full agonist chemical which can activate other aspects of disease

Access to chemical that has a high risk of diversion (high street value)

Marked variability in quality of treatment services

Resistance of many addicted persons to go to methadone clinic for treatment

Does Methadone Cause Cognitive Impairment? Studies using driving simulators show

minimal decrease in reflexes, response to danger

Memory function impairment is documented and is dose-related

No large-scale long term studies of higher cognitive functions Judgment and decision-making Abstract reasoning Capacity for new learning of complex

concepts or fine motor skills

Buprenorphine

Partial agonist at the mu receptor When attached to the receptor, prevents

other opioids from binding Has been used for pain management for

many years, as injectable drug (Buprenex®) Reformulated as sublingual tablet

Subutex®- buprenorphine only Suboxone®- buprenorphine plus naloxone

Now available as film (dissolves on tongue)

Buprenorphine: Advantages How medication is provided

Can be prescribed by trained physicians Office-based setting, increased privacy More attractive to prescription drug addicts

Self-administered at home Pharmacology of drug

As partial agonist, less danger of overdose and diversion, especially when combined with naloxone

Less difficulty with detoxification (?)

Buprenorphine: Disadvantages

Cost As brand-name medication, Suboxone®,

Subutex® MUCH more expensive than methadone

Not covered by all private insurers or Medicaid Availability

Not stocked by all pharmacies Concern about diversion risks

Lack of required comprehensive treatment

Does Buprenorphine Cause Cognitive Impairment?

Most studies of patients in early treatment show some decrease in working memory and attention which improves over time

Overall less impairment than methadone

No studies of higher “executive” function

Antagonist Therapy Basic concept: replace the drug of addiction with

drug that does not activate the receptor, but prevents other drugs from binding and activating it

Examples: Naltrexone blocks mu opioid receptor Buprenorphene blocks other opioids Varenicline (Chantix®)- blocks nicotinic ACTH

receptor to nicotine

Anti-Craving Therapies

Acamprosate (Campral®) Naltrexone (ReVia®, Vivitrol®) Anticonvulsants*

Topirimate (Topamax®) Gabapentin (Neurontin®) Pregabalin (Lyrica®)

* off-label

Immunologic Approaches

Vaccines developed that prevent absorption of various drugs via antibody response

Research under way for several drugs Cocaine Methamphetamine Nicotine

Aversive Approaches Disulfuram (Antabuse®)

Has been around since 1950s Adjunct to alcohol abstinence via blocking

metabolism of aldehyde dehydrogenase Improves outcomes for cocaine abstinence, with

or without alcoholism, possibly by inhibiting dopamine beta hydroxylase

Buproprion (Wellbutrin SR®, Zyban®) Gives cigarettes a noxious taste Primarily works on dopamine and ACTH receptors

Medications for Co-occurring Disorders

Psychiatric Antidepressants Mood stabilizers Antipsychotics Anxiolytics and sedatives Stimulants

Medical Analgesics

Opioids Non-opioids

Others

Psychological Complications for Addicts Taking Medications Irrational thinking about medications

common among addicted persons “If I take these pills I won’t have to go to meetings or

group therapy.” “If one pill helps some, more will help better.” “Now that I’m on medication, maybe I can drink socially

(smoke pot socially, etc.).” “Having this pill bottle in my hand gives me cravings.”

Non-adherence as a way of life

Addressing These Issues with Patients

Discuss the purpose of medication, emphasizing that it is only part of treatment

Discuss “more is better” trap Reinforce basics of disease

Cross-addiction Chronicity

Prepare patient for and normalize cravings Explore adherence vs. compliance, attitude

toward rules, authority figures

Medication and Twelve Step Programs

Some members of AA or NA have strong opinions on medications for recovering alcoholics/ addicts Antipsychotics Mood stabilizers Antidepressants Anxiolytics and sleeping pills Anti-craving, antagonist or aversive medications

Alcoholics Anonymous and Narcotics Anonymous have no opinion on medications as such (Tradition Ten) See the AA pamphlet “The AA Member- Medications and Other

Drugs” P-11 Twelve Step programs do recognize pre-sensitization (“cross-

addiction”)and the need to protect your brain Agonist treatments are viewed differently and such persons may

be more comfortable in specialized meetings (Methadone Anonymous, etc.)

Special Fellowships for Persons with Co-Occurring Disorders Dual Recovery Anonymous (DRA)

[www.dra.org] Based on 12 Steps of AA Requirements for attendance

A desire to stop using alcohol or other intoxicating drugs A desire to manage our emotional or psychiatric illness in a

healthy and constructive way

Double Trouble in Recovery (DTR) [www.doubletroubleinrecovery.org] Based on 12 Steps of AA Working together to recovery from both chemical

dependency and mental disorders