Can Medications Treat Addiction?
Addiction is a chronic and often-progressive medical issue and, like other conditions of this sort, research is ongoing in the hopes of developing new pharmaceutical and medical treatments for it. Presently, there are a limited number of FDA approved medications indicated to treat alcohol use disorders and opioid use disorders. In addition to these, some treatment professionals may incorporate other medications for off-label use in helping people in recovery from a variety of substance addictions. Within the realm of addiction treatment, medications have commonly been referred to as the pharmaceutical portion of medication-assisted therapy (MAT), though the more straightforward concept of addiction pharmacotherapy has come into increasingly widespread use.
While medications alone may not reliably lead to sustained recovery, they can contribute to the success of a treatment plan. As part of a comprehensive addiction treatment strategy, medications may be used in conjunction with other evidence based approaches to drug abuse treatment, including group and individual behavioral therapy sessions and mutual support meetings.
Medications for Opioid Use Disorder
The opioid class of drugs includes illicit substances like heroin as well as several prescription painkillers such as morphine and hydrocodone. Opioid drugs have a high abuse liability in part due to their strong reinforcing effects. Additionally, significant physical dependence and an accompanying withdrawal syndrome, are common elements of many opioid use disorders. Acute opioid withdrawal is notoriously unpleasant, which presents additional challenges to recovery. Many people will continue to use opioids or relapse when confronted with the uncomfortable symptoms of withdrawal.
Important goals of medication treatment for opioid addiction include making the withdrawal process significantly more comfortable and alleviating cravings. Opioid agonist medications including methadone and buprenorphine, as well as buprenorphine/naloxone combinations (e.g., Suboxone), can help the recovering person avoid a relapse during the withdrawal process and the maintenance phase of treatment inside and outside of a rehab program.
Each of these medications will be discussed further, but at this juncture, it is helpful to broadly discuss how opioids work in the brain. In turn, may be is easier to understand how medications that treat addiction work at the neurological level. Although psychopharmacology can be complicated, a few basics about the interaction of drugs and the brain can be illuminating.
How Opioid Addiction Medications Work
There are three main categories that are referred to in the literature regarding medications to treat opioid addiction: full opioid agonists, partial opioid agonists, and opioid antagonists. Methadone is classified as a full opioid agonist, buprenorphine is a partial opioid agonist, and naltrexone is an opioid antagonist. These classifications reflect the different types of activity each of these medications has on opioid receptor sites.
As methadone is a full opioid agonist, it binds to and fully activates mu opioid receptors. In doing so, methadone can suppress withdrawal, stop other opioids from docking in the receptor site and having euphoric effects, and reduce cravings for opioids.
Now that it is established how methadone works, it is useful to know how it fits into the recovery treatment framework. Most often, the recovery process begins with medical detox. After detox is complete and the recovering person is safely stabilized on methadone, the next stage is methadone maintenance. Some individuals will choose to remain on methadone for months, years, or a lifetime, while others will use this treatment as a precursor to full abstinence at some point in the future.
The following are some of the most well-documented pros and cons of methadone treatment:
- Dosing lasts for at least 24 hours.
- Daily clinic visits for dosing provides some medical oversight of the recovery process.
- Methadone distribution clinics typically offer counseling or arrange for counseling elsewhere.
- Meeting other similarly situated recovering individuals can be therapeutic.
- It is a time-tested treatment approach to treat opioid addiction.
- Some people continue to use opioids while taking methadone.
- Methadone is itself a drug of abuse.
- Daily visits to the methadone distribution clinic can present a disincentive to stay in treatment.
- Methadone will cause those to test positive for drugs, which can present a challenge for employment, residence in a sober living home, and other issues.
- Daily visits to the methadone clinic can induce feelings of low self-esteem despite the person’s progress.
As noted above, methadone maintenance requires a person to make daily, or near daily, visits to a methadone distribution clinic. Some people may be unable to do so due to disability, transportation limitations, or a general apathy toward treatment. A person who is not a candidate for methadone treatment may be a better candidate for buprenorphine, buprenorphine/naloxone, naltrexone, or an abstinence-focused method that does not involve any drugs.
Buprenorphine, being a partial opioid agonist, partially activates the opioid receptor site and has an upper limit to its opioid effects. As an opioid treatment drug, buprenorphine may be administered alone or in combination products that include naloxone. Suboxone is a brand name buprenorphine product that also includes naloxone, an opioid antagonist. Naloxone is included in this combination product to cut down on the abuse potential of the treatment drug itself, such as through attempts to inject the dissolved medication.
The U.S. Food and Drug Administration approved buprenorphine for clinical use in 2002, and this drug was considered a significant advancement in the field of addiction treatment science. One of the most touted aspects of buprenorphine is that it is more convenient than methadone maintenance. There is no need for a daily visit to a buprenorphine distribution clinic because buprenorphine is the first addiction treatment medication that can be prescribed in a host of medical settings, including a doctor’s office.
When buprenorphine and buprenorphine products are used, they are involved in addiction recovery treatment in three phases: the induction phase, the stabilization phase, and the maintenance phase. The induction phase typically begins 12-24 hours after last use of an opioid. A qualified doctor or certified opiate treatment program (OTP) will determine the best buprenorphine medication to use. The treating medical personnel will determine appropriate dosing. If people have any opioids in their systems, the use of buprenorphine can precipitate intense withdrawal symptoms. For this reason, this first step is often taken under the supervision of a medical professional.
The stabilization phase is considered to begin after a person has considerably detoxed from the opioid of abuse and experiences few, if any, cravings or other side effects. At this stage, the attending medical personnel may continue to adjust the dosing to accurately track and meet the recovering person’s needs. Since buprenorphine is long-acting, after clients are stabilized, they may be able to take buprenorphine every other day rather than daily.
Once recovering people have demonstrated responsiveness to buprenorphine and have a sufficient amount of stabilization time under their belts, they are considered to be in the maintenance phase. The duration of the maintenance phase can be months, years, or a lifetime.
As naltrexone is an opioid receptor antagonist, it is able to block other opioids from docking onto the opioid receptor site, but it does not activate the site itself; hence, there are no psychoactive or reinforcing effects associated with naltrexone use.
One branded formulation of naltrexone, called Vivitrol is a long-acting injectable medication Studies have shown each medication can be effective decreasing both opioid use and drinking behaviors. Hence, naltrexone is unique compared to methadone and buprenorphine in that it has specifically been indicated in the treatment of both alcohol use and opioid use disorders.
Due to the pharmacologic mechanism, it is imperative that those initiated on this medication are not at risk of experiencing opioid withdrawal symptoms, such as those who have yet to complete an opioid detox program.
Addiction Treatment and Recovery
Recovery is an interactive process between the recovering person’s goals and the treatment staff’s clinical expertise. In order to ensure participation and comfort in the recovery process, a rehab program will necessarily factor in a recovering person’s reasonable goals, provided those goals do not compromise the effectiveness of treatment.
It is important to understand that though the use of medications to treat opioid addiction is increasingly becoming the standard of care, it is still not universally embraced by all in the treatment community. Such use may depend on the treatment center’s philosophy of recovery and established treatment curriculum. However, an effective recovery plan is one optimized to ensure a person achieves and maintains abstinence, and this often includes the option to use medications to address addiction.