Where Are You Regarding Pharmacotherapy for Addictive Disorders?

I use the term “pharmacotherapy” to describe the use of medications to assist people with substance use disorders to achieve remission—that is, no longer meeting the diagnostic criteria for an active addiction—or even better, to achieve recovery. Although psychiatric medications are also a type of pharmacotherapy, I have chosen to limit the article to antiaddiction drugs.

Let me begin by telling you that I very strongly dislike the term “medication-assisted treatment” (MAT) and my objection stems from two sources. The first is that MAT is closely associated with opioid replacement or opioid maintenance treatment such as methadone or buprenorphine, in its Subutex or Suboxone forms. Even as late as 2011, the Substance Abuse and Mental Health Services Administration (SAMHSA) was using the term to denote treatment for opioid dependence. Many counselors, particularly those who come from a Twelve Step, disease model orientation, have strong, negative views about opioid replacement treatment, especially methadone and therefore may have an immediate, strongly disapproving reaction to the term “MAT.”

In addition, the term “MAT” is often viewed too narrowly. In addition to opioid replacement drugs that are agonists, meaning drugs that substitute for the abused opioid, there are partial agonists such as buprenorphine, there are antagonists—drugs that reduce craving and block the effects of the opioids or alcohol—such as oral naltrexone, extended release injectable naltrexone (Vivitrol) and acamprosate (Campral), and the aversive drug disulfiram (Antabuse) used for alcohol use disorders. 

My second objection to MAT is about the inconsistency that often exists between what we say and our behavior in relation to our words. While we characterize addiction as a chronic disease, the language we use to describe addiction does not correspond to what we say. If we truly believe that addiction is a chronic illness, we should be treating it as such. 

For example, the treatment of diabetes includes such things as reducing carbohydrate intake, weight management, monitoring blood sugar, being physically active, smoking cessation, and frequently using medication to help control blood sugar. When a diabetic uses medication to manage blood sugar, we don’t refer to it as MAT; it is merely one of the components of that individual’s treatment. However, with addiction we separate the medication from the other treatment components. What might account for this?

We need to look no further than the history of alcoholism treatment to understand some of the resistance and objection to pharmacotherapy. The reason why we have an addiction treatment community today in which the majority of the clinicians are alcohol and drug counselors, many  in recovery themselves, is that in the 1950s and 1960s much of the professional treatment community abdicated their responsibility to treat people with substance use disorders. Complicating this was the astonishing lack of knowledge about the disease and its appropriate treatment. At that time the prevailing perception of alcoholism among medical and psychiatric clinicians was that alcoholism was not a disease, but rather a symptom of an underlying psychiatric disorder—if the psychiatric part was resolved, then drinking would no longer be a problem. Given an individual who had a major depressive disorder and an alcohol use disorder, the primary treatment strategy by those who held this belief was to prescribe antidepressive drugs to “cure” the alcoholism. Instead, what we ended up with was “a happy drunk.” 

Other derisive comments are that the physician’s definition of alcoholism was “anyone who drinks more than me” and that “the etiology of alcoholism is a Valium deficiency.” This last was very damaging because many alcoholics were prescribed a benzodiazepine for the treatment of their alcoholism, not limited to withdrawal management, only to end up with cross dependence on both the benzodiazepine and alcohol. It is therefore no wonder that there exists the reluctance, if not outright opposition to the use of pharmacotherapy. This is all reminiscent of the field’s past resistance or refusal to use psychiatric medications for those patients who had serious mental health disorders. The net result was to deprive such patients the opportunity to recover from both their mental health and substance use disorders.

There are clear differences between agonist or opioid replacement and antagonist drug treatment.  In the former, a longer acting opioid such as methadone is substituted for the opioid the individual has been using. The purpose is to stabilize the individual, reduce or eliminate craving, relapse, and overdoses, reduce the criminal behavior associated with the acquisition of the drugs of abuse, and generally help the addict to become a more productive citizen (CDC, 2002). Very importantly, for pregnant opioid addicts, methadone reduces the more frequent withdrawal to heroin experienced by the fetus. Federal regulations specify admission criteria and other components of methadone programs.

I suspect that the same people who are opposed to the use of methadone are those who strongly opposed the legalization of recreational illicit drugs. The answer to the question of whether or not to legalize illicit drugs is that it depends on what outcome you are seeking. If what you wish is to reduce criminal behavior associated with the use and acquisition of illicit drugs, then legalize; we can all learn from the noble experiment called “prohibition.” If on the other hand you wish to improve the health status of users and enhance their social and family functioning, don’t legalize.

Because it is methadone “maintenance,” it is accurate that the person does not become drug free and achieve abstinence. Similarly to the aforementioned issue of legalization, if the goal of treatment is abstinence, methadone is clearly not the treatment of choice. On the other hand, if the goal is to reduce criminal behavior associated with the use of the drugs and increase employment and responsibility to family and community, there is over fifty years of research data supporting its use.

A very common objection raised to the use of methadone is that if an opioid dependent person is on methadone, they are “still addicted.” This statement is patently inaccurate. Addiction includes four components: loss of control, compulsion; continued use in spite of adverse consequences, and craving. If the methadone patient is not abusing his or her methadone or any other psychoactive drug, they are not “still addicted.” Rather, they remain physiologically dependent on the opioids. It is likely that anyone who uses high doses of an opioid regularly may become physically dependent, sometimes in as little as ten days as may happen when a patient undergoes major surgery and is prescribed opioids for the management of pain or for the management of cancer pain (Weissman, Dahl, & Dinndorf, 1996). However, their physical dependence is treated by gradually reducing the dosage of the drug over time. At the conclusion of that process the individual does not go running around looking for a fix because he or she was not addicted but physiologically dependent. 

In contrast to agonists like methadone, antagonists do not create or continue physiological dependence, there is no withdrawal upon discontinuation and in fact, there is no psychoactive effect from using the drug. These drugs have the effect of either reducing craving and/or minimizing the effect of the drug of choice if the individual uses again while on the antagonist. Acamprosate (Campral) is FDA approved for the treatment of alcohol dependence while oral naltrexone (Depade and Revia) and extended release, injectable naltrexone (Vivitrol) are FDA approved for treatment of both alcohol and opioid dependence. There is a large and growing body of evidence of the efficacy of antagonists, particularly Vivitrol, because since it is a once-a-month injection, it overcomes most of the problems associated with daily medication adherence.

There is one drug that is in a class by itself and that is disulfiram (Antabuse), approved for use with alcohol disorders, although incidentally not an FDA-approved use for use in the treatment of cocaine disorders, where there has been a growing body of evidence indicating that the drug may have benefits. This is an aversive drug, and in contrast to agonist and antagonists it does not substitute for the effects of alcohol nor directly reduces craving. If the individual ingests alcohol drinks within five days to two weeks of stopping Antabuse, the drug stops the breakdown of alcohol at the stage of acetaldehyde which is toxic, creating a number of very unpleasant symptoms such flushing, tachycardia, sweating, and nausea. The thinking underlying its use is that the individual will not drink for at least five days after stopping the drug in order to avoid this very unpleasant reaction (Fishman, Shulman, Mee-Lee, Kolodner, & Wilford, 2010). Disulfiram may be effective for no more than moderately impulsive alcoholics and can be used for short term “insurance” as with an alcoholic patient who must temporarily leave residential or inpatient treatment to attend activities associated with a death in the family (Fishman et al., 2010). Care needs to be exercised because gargling with an alcohol-based mouthwash or eating food incompletely cooked in wine can also precipitate the reaction.

None of the drugs we have been discussing are “magic bullets” and one clear recommendation for all these  medications is that they be used in conjunction with psychosocial treatment and/or recovery support groups. A common question asked of me is, “How long does a person need to be on it?” There is no standard answer. Some drugs such as Vivitrol are generally used until the reduction in craving has permitted the individual to benefit from treatment and is now stable in early recovery three to six months or even a year. There are some individuals who have been using Antabuse or methadone for twenty years, their philosophy being “If it ain’t broke, don’t fix it!” Increasingly, people on methadone who want to get off of methadone may first transition to buprenorphine as an intermediate step in moving to becoming drug free. In the final analysis it comes down to a decision between the patient and physician as to when it is the best time to terminate the use of the antiaddiction drug.

So where does all this leave us? If we would not deny someone with schizophrenia a neuroleptic, if we would not deny someone with a bipolar disorder a mood stabilizer or, if we would not deny someone with a major depressive disorder an antidepressant, why should we be opposed to providing someone with an addictive disorder a drug that could assist their treatment in their journey to recovery? 

Fishman, M. J., Shulman, G. D., Mee-Lee, D., Kolodner, G., & Wilford, B. B. (Eds.) (2010). ASAM supplement on pharmacotherapies for alcohol use disorders. Chevy Chase, MD: American Society of Addiction Medicine. 

Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). Medication-assisted treatment for opioid addiction. Retrieved from http://store.samhsa.gov/shin/content/SMA09-4443/SMA09-4443.pdf 

Weissman, D. E., Dahl, J. L., Dinndorf, P. A. (1996). Handbook of cancer pain management (5th ed.). Madison, WI: WCPI.