Addiction medicines are seen as aids and tools for clinical treatment and to be prescribed to patients as part of a treatment plan that integrates the use of medications with good clinical behavioral treatment.
For alcohol abusers: Naltrexone, marketed since 1994 is the first medication since antabuse that has been approved for the treatment of alcoholism. Naltrexone blocks the pleasurable effects of alcohol and reduces cravings.
Naltrexone is safe (the most common side effect is nausea), but liver damage can occur if the medication is used in high doses. It is also recommended that counseling or support groups must accompany the use of Naltrexone.
Naltrexone is also used in opiate-dependent patients.
It is an opiate receptor blocker or antagonist.
Studies have shown that the use of naltrexone in opiate-dependent patients who have significant social and medical consequences, such as physicians, have been the most successful group to use naltrexone. As an opiate blocker, it has a long-lasting effect after oral dosing of up to 3 days.
This medication is currently used in anesthesia to reverse the effects of narcotic pain relievers. A recent study shows that nalmefene, an opioid antagonist, is effective in reducing cravings and preventing relapse to heavy drinking in alcohol-dependent patients.
Nalmephene is a “universal” opioid antagonist that works on all opioid receptors. It appears to last longer and be more potent than Naltrexone.
Acamprosate, is available in Europe and will be marketed in the United States as Campral. It it enhances abstinence and reduces “drinking days” in the alcohol-dependent patient. Of great importance is that it is not metabolized in the liver. This will reduce many of the worries of Naltrexone for the advanced alcohol-dependent patient with liver disease.
Buprenorphine will be used as an opiate detoxification and opiate maintenance agent.
There will be two forms of the medication:
Sublingual (under the tongue) tablet called Subutex® and Buprenorphine combined with Naloxone called Suboxone® that prevents intravenous use of the tablet after crushing.
Buprenorphine is much less likely to cause respiratory depression which is the limiting factor in the use of opiates and causes much of the adverse consequences of use and overdose.
Studies are underway to look at the possibility of buprenorphine use to reduce opiate and cocaine craving.
Clonidine was originally used solely for treatment of hypertension, Clonidine acts to reduce the heart rate and relaxes and dilates blood vessels, resulting in a lowered blood pressure. Studies have found that clonidine is useful in treating opiate withdrawal, alcohol withdrawal and nicotine dependence, though it is said to be ineffective in benzodiazepine (tranquilizer) detoxification. Its major side effects are a decrease in blood pressure, dry mouth and sedation. When used for opiate detoxification, symptoms such as lethargy, restlessness, insomnia and craving are not well relieved.
Overall, it tends to improve signs and symptoms of withdrawal, although its does not alter the time course of withdrawal.
Lofexidine is a medication that is similar to clonidine (used in opiate withdrawal and by some in alcohol withdrawal and nicotine withdrawal treatment protocols). While clonidine has major side effects which include sedation and a lowering of the blood pressure which can sometimes prevent it from being used, Lofexidine does not have the same impact on blood pressure, and may be a medication with which patients are more compliant.
Antabuse produces a sensitivity to alcohol which results in a highly unpleasant reaction when the individual under treatment ingests alcohol. The mechanism of action is the blockade of the metabolism of alcohol (oxidation). A product of this oxidation is acetaldehyde. If antabuse is taken, the metabolism stops at the point of acetaldehyde production and there will be an increase in the concentration of acetaldehyde 5 – 10 times higher than in normal alcohol metabolism.
The accumulation of acetaldehyde produces the “antabuse reaction.”
This reaction can range from a flush and throbbing in the head and neck to nausea, vomiting, breathing difficulty, chest pain, heart failure and possible death.
This medication cannot be given to anyone with a history of severe heart disease, psychosis, allergy to antabuse, pregnancy, paraldehyde use or metronidazole use. It must be used with caution in the patient with a history of diabetes, seizures and liver disease. Antabuse can be of benefit when used in conjunction with a comprehensive treatment program for alcohol dependence.
Gabapentin is an anticonvulsant sold under the name Neurontin®. It is being used for pain management and anxiety, though some of the more interesting work is in the field of insomnia, a problem that is very common among alcohol – dependent patients.
Ondansetron is a medication used to treat nausea in chemotherapy patients and is sold under the name Zolfran®. Serotonin is implicated in alcohol-abuse behavior, especially in regard to the serotonin receptor and its effect on dopamine. If this receptor could be blocked, there would be a decrease in alcohol-induced dopamine release, resulting in a decrease in alcoholic drinking behavior.
Methadone is a synthetic narcotic that was developed in Germany during WWII. In 1963, Drs. Dole and Nyswander treated opiate addicts with methadone to control craving. In 1972, it was approved by the FDA for the treatment of narcotic dependence. It is a highly regulated medication that can only be prescribed by a licensed clinic or, on an emergency basis, in a general hospital for addiction treatment. It can be ordered by a licensed physician for the treatment of pain as an outpatient. With a very favorable side effect profile, it is an extremely effective and safe medication. Of extra benefit, there is blood – level testing that can help to individualize treatment.
There are many centers that administer methadone in the US, from Utah methadone programs to similar programs in practically every state.
This is the first non-nicotine medication approved for smoking cessation. The medication works on cravings and withdrawal at the brain level through dopaminergic and noradrenergic pathways. It is successfully used alone or in combination with nicotine-replacement medications (patches, gum). The most common side effect is dry mouth and insomnia. It cannot be used in patients with seizure disorders, bulimia, anorexia, pregnancy, allergy to bupropion or those already treated with Wellbutrin®.
OASAS Addiction Medicine website: http://www.oasas.state.ny.us/
National Institute on Alcohol Abuse and Alcoholism: http://www.niaaa.nih.gov/
National Institute on Drug Abuse: http://www.nida.nih.gov/