Medications In Addiction Treatment


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The Farley Professional Lecture Series Presentation
February 25, 2011

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Medications In Addiction Treatment

  1. 1. Medications in Addiction Treatment Penelope P. Ziegler, M.D. Medical Director Virginia Health Practitioners’ Monitoring Program
  2. 2. Pharmacotherapy for Addiction <ul><li>Medically managed withdrawal (detoxification)- ACUTE </li></ul><ul><li>Management of co-occurring psychiatric, medical disorders- ACUTE and/or CONTINUING </li></ul><ul><li>Maintenance of recovery- CONTINUING </li></ul>
  3. 3. Pharmacologic Interventions for Maintenance of Recovery <ul><li>Agonist therapies </li></ul><ul><li>Antagonist therapies </li></ul><ul><li>Anti-craving therapies </li></ul><ul><li>Immunological approaches </li></ul><ul><li>Aversive therapies </li></ul><ul><li>Medications to treat co-occurring psychiatric or medical disorders </li></ul>
  4. 4. Agonist Therapy <ul><li>Basic concept: replace drug of addiction with safer alternative that activates same receptor </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Opioid agonist- methadone </li></ul></ul><ul><ul><li>Opioid partial agonist- buprenorphine , others </li></ul></ul><ul><ul><li>Nicotine agonist- nicotine replacement </li></ul></ul><ul><ul><li>Nicotine partial agonist- varenicline </li></ul></ul>
  5. 5. Methadone <ul><li>Full agonist at the mu receptor </li></ul><ul><li>Can be used for detoxification </li></ul><ul><ul><li>Rapid (3-5 days) </li></ul></ul><ul><ul><li>Prolonged (1-6 months or longer) </li></ul></ul><ul><li>Most often used for maintenance </li></ul><ul><li>Administered in federally licensed clinics under careful monitoring </li></ul><ul><ul><li>Not-for-profit community-based clinics </li></ul></ul><ul><ul><li>Clinics associated with teaching and research </li></ul></ul><ul><ul><li>For-profit private clinics </li></ul></ul>
  6. 6. Methadone: Advantages <ul><li>Improved outcomes </li></ul><ul><ul><li>Methadone maintenance treatment has dramatically better outcomes than drug-free treatment, including detox, short- or long-term residential programs or outpatient care </li></ul></ul><ul><ul><li>Persons in methadone treatment are less likely to experience common complications of addiction </li></ul></ul><ul><ul><ul><li>Criminal behavior </li></ul></ul></ul><ul><ul><ul><li>Infectious disease </li></ul></ul></ul><ul><ul><ul><li>Drug-related violence </li></ul></ul></ul><ul><li>Comprehensive treatment approach </li></ul><ul><ul><li>Clinics provide and require variety of psychosocial interventions and therapies </li></ul></ul><ul><ul><li>Particularly useful for persons who need “life training” </li></ul></ul>
  7. 7. Methadone: Disadvantages <ul><li>Continued use of full agonist chemical which can activate other aspects of disease </li></ul><ul><li>Access to chemical that has a high risk of diversion (high street value) </li></ul><ul><li>Marked variability in quality of treatment services </li></ul><ul><li>Resistance of many addicted persons to go to methadone clinic for treatment </li></ul>
  8. 8. Does Methadone Cause Cognitive Impairment? <ul><li>Studies using driving simulators show minimal decrease in reflexes, response to danger </li></ul><ul><li>Memory function impairment is documented and is dose-related </li></ul><ul><li>No large-scale long term studies of higher cognitive functions </li></ul><ul><ul><li>Judgment and decision-making </li></ul></ul><ul><ul><li>Abstract reasoning </li></ul></ul><ul><ul><li>Capacity for new learning of complex concepts or fine motor skills </li></ul></ul>
  9. 9. Buprenorphine <ul><li>Partial agonist at the mu receptor </li></ul><ul><li>When attached to the receptor, prevents other opioids from binding </li></ul><ul><li>Has been used for pain management for many years, as injectable drug (Buprenex®) </li></ul><ul><li>Reformulated as sublingual tablet </li></ul><ul><ul><li>Subutex®- buprenorphine only </li></ul></ul><ul><ul><li>Suboxone®- buprenorphine plus naloxone </li></ul></ul><ul><li>Now available as film (dissolves on tongue) </li></ul>
  10. 10. Buprenorphine: Advantages <ul><li>How medication is provided </li></ul><ul><ul><li>Can be prescribed by trained physicians </li></ul></ul><ul><ul><ul><li>Office-based setting, increased privacy </li></ul></ul></ul><ul><ul><ul><li>More attractive to prescription drug addicts </li></ul></ul></ul><ul><ul><li>Self-administered at home </li></ul></ul><ul><li>Pharmacology of drug </li></ul><ul><ul><li>As partial agonist, less danger of overdose and diversion, especially when combined with naloxone </li></ul></ul><ul><ul><li>Less difficulty with detoxification (?) </li></ul></ul>
  11. 11. Buprenorphine: Disadvantages <ul><li>Cost </li></ul><ul><ul><li>As brand-name medication, Suboxone®, Subutex® MUCH more expensive than methadone </li></ul></ul><ul><ul><li>Not covered by all private insurers or Medicaid </li></ul></ul><ul><li>Availability </li></ul><ul><ul><li>Not stocked by all pharmacies </li></ul></ul><ul><ul><li>Concern about diversion risks </li></ul></ul><ul><li>Lack of required comprehensive treatment </li></ul>
  12. 12. Does Buprenorphine Cause Cognitive Impairment? <ul><li>Most studies of patients in early treatment show some decrease in working memory and attention which improves over time </li></ul><ul><li>Overall less impairment than methadone </li></ul><ul><li>No studies of higher “executive” function </li></ul>
  13. 13. Antagonist Therapy <ul><li>Basic concept: replace the drug of addiction with drug that does not activate the receptor, but prevents other drugs from binding and activating it </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Naltrexone blocks mu opioid receptor </li></ul></ul><ul><ul><li>Buprenorphene blocks other opioids </li></ul></ul><ul><ul><li>Varenicline (Chantix®)- blocks nicotinic ACTH receptor to nicotine </li></ul></ul>
  14. 14. Anti-Craving Therapies <ul><li>Acamprosate (Campral®) </li></ul><ul><li>Naltrexone (ReVia®, Vivitrol®) </li></ul><ul><li>Anticonvulsants* </li></ul><ul><ul><li>Topirimate (Topamax®) </li></ul></ul><ul><ul><li>Gabapentin (Neurontin®) </li></ul></ul><ul><ul><li>Pregabalin (Lyrica®) </li></ul></ul><ul><ul><ul><li>* off-label </li></ul></ul></ul>
  15. 15. Immunologic Approaches <ul><li>Vaccines developed that prevent absorption of various drugs via antibody response </li></ul><ul><li>Research under way for several drugs </li></ul><ul><ul><li>Cocaine </li></ul></ul><ul><ul><li>Methamphetamine </li></ul></ul><ul><ul><li>Nicotine </li></ul></ul>
  16. 16. Aversive Approaches <ul><li>Disulfuram (Antabuse®) </li></ul><ul><ul><li>Has been around since 1950s </li></ul></ul><ul><ul><li>Adjunct to alcohol abstinence via blocking metabolism of aldehyde dehydrogenase </li></ul></ul><ul><ul><li>Improves outcomes for cocaine abstinence, with or without alcoholism, possibly by inhibiting dopamine beta hydroxylase </li></ul></ul><ul><li>Buproprion (Wellbutrin SR®, Zyban®) </li></ul><ul><ul><li>Gives cigarettes a noxious taste </li></ul></ul><ul><ul><li>Primarily works on dopamine and ACTH receptors </li></ul></ul>
  17. 17. Medications for Co-occurring Disorders <ul><li>Psychiatric </li></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Mood stabilizers </li></ul></ul><ul><ul><li>Antipsychotics </li></ul></ul><ul><ul><li>Anxiolytics and sedatives </li></ul></ul><ul><ul><li>Stimulants </li></ul></ul><ul><li>Medical </li></ul><ul><ul><li>Analgesics </li></ul></ul><ul><ul><ul><li>Opioids </li></ul></ul></ul><ul><ul><ul><li>Non-opioids </li></ul></ul></ul><ul><ul><li>Others </li></ul></ul>
  18. 18. Psychological Complications for Addicts Taking Medications <ul><li>Irrational thinking about medications common among addicted persons </li></ul><ul><ul><li>“ If I take these pills I won’t have to go to meetings or group therapy.” </li></ul></ul><ul><ul><li>“ If one pill helps some, more will help better.” </li></ul></ul><ul><ul><li>“ Now that I’m on medication, maybe I can drink socially (smoke pot socially, etc.).” </li></ul></ul><ul><ul><li>“ Having this pill bottle in my hand gives me cravings.” </li></ul></ul><ul><li>Non-adherence as a way of life </li></ul>
  19. 19. Addressing These Issues with Patients <ul><li>Discuss the purpose of medication, emphasizing that it is only part of treatment </li></ul><ul><li>Discuss “more is better” trap </li></ul><ul><li>Reinforce basics of disease </li></ul><ul><ul><li>Cross-addiction </li></ul></ul><ul><ul><li>Chronicity </li></ul></ul><ul><li>Prepare patient for and normalize cravings </li></ul><ul><li>Explore adherence vs. compliance , attitude toward rules, authority figures </li></ul>
  20. 20. Medication and Twelve Step Programs <ul><li>Some members of AA or NA have strong opinions on medications for recovering alcoholics/ addicts </li></ul><ul><ul><li>Antipsychotics </li></ul></ul><ul><ul><li>Mood stabilizers </li></ul></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Anxiolytics and sleeping pills </li></ul></ul><ul><ul><li>Anti-craving, antagonist or aversive medications </li></ul></ul><ul><li>Alcoholics Anonymous and Narcotics Anonymous have no opinion on medications as such (Tradition Ten) </li></ul><ul><ul><li>See the AA pamphlet “The AA Member- Medications and Other Drugs” P-11 </li></ul></ul><ul><ul><li>Twelve Step programs do recognize pre-sensitization (“cross-addiction”)and the need to protect your brain </li></ul></ul><ul><ul><li>Agonist treatments are viewed differently and such persons may be more comfortable in specialized meetings (Methadone Anonymous, etc.) </li></ul></ul>
  21. 21. Special Fellowships for Persons with Co-Occurring Disorders <ul><li>Dual Recovery Anonymous (DRA) [] </li></ul><ul><ul><li>Based on 12 Steps of AA </li></ul></ul><ul><ul><li>Requirements for attendance </li></ul></ul><ul><ul><ul><li>A desire to stop using alcohol or other intoxicating drugs </li></ul></ul></ul><ul><ul><ul><li>A desire to manage our emotional or psychiatric illness in a healthy and constructive way </li></ul></ul></ul><ul><li>Double Trouble in Recovery (DTR) [ ] </li></ul><ul><ul><li>Based on 12 Steps of AA </li></ul></ul><ul><ul><li>Working together to recovery from both chemical dependency and mental disorders </li></ul></ul>