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Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
Medications In Addiction Treatment
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Medications In Addiction Treatment

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The Farley Professional Lecture Series Presentation …

The Farley Professional Lecture Series Presentation
February 25, 2011

Published in: Health & Medicine
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  • 1. Medications in Addiction Treatment Penelope P. Ziegler, M.D. Medical Director Virginia Health Practitioners’ Monitoring Program
  • 2. Pharmacotherapy for Addiction
    • Medically managed withdrawal (detoxification)- ACUTE
    • Management of co-occurring psychiatric, medical disorders- ACUTE and/or CONTINUING
    • Maintenance of recovery- CONTINUING
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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”
  • 7. 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
  • 8. 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
  • 9. 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)
  • 10. 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 (?)
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. Anti-Craving Therapies
    • Acamprosate (Campral®)
    • Naltrexone (ReVia®, Vivitrol®)
    • Anticonvulsants*
      • Topirimate (Topamax®)
      • Gabapentin (Neurontin®)
      • Pregabalin (Lyrica®)
        • * off-label
  • 15. Immunologic Approaches
    • Vaccines developed that prevent absorption of various drugs via antibody response
    • Research under way for several drugs
      • Cocaine
      • Methamphetamine
      • Nicotine
  • 16. 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
  • 17. Medications for Co-occurring Disorders
    • Psychiatric
      • Antidepressants
      • Mood stabilizers
      • Antipsychotics
      • Anxiolytics and sedatives
      • Stimulants
    • Medical
      • Analgesics
        • Opioids
        • Non-opioids
      • Others
  • 18. 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
  • 19. 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
  • 20. 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.)
  • 21. 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

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