The controversy regarding the use of medications in active addiction and in recovery continues. At the most recent American Society of Addiction Medicine Conference in New Orleans, there were very heated and spirited discussions on the use of medications in active addiction as well as medicine use in early and sustained recovery. (There were also many discussions on “What is Addiction and What is Recovery?”, but that will have to wait for another time.)

On one side of the debate are those who feel that true recovery has to be achieved and maintained without the use of all chemicals including prescription medications. They persuade those looking for recovery that all medicines are contra-indicated including relapse prevention medicines as well as medicines prescribed for depression, anxiety or other co-occurring disorders .

On the other side of the debate are those who believe that most medications are allowed in recovery as long as they are “prescribed by a doctor” and that there are some that even increase the chance of prolonged sobriety. Their belief system is centered in the Western Medicine concept that diseases of the mind and body have a pathological basis and that we have the understanding and chemical knowledge to address and treat the underlying pathology with medications. Most traditional medical doctors are trained to treat a disease process with both behavioral recommendations as well as medicines. For example, the treatment of diabetes involves dietary interventions, exercise and medications.

The authors believe that the truth lies somewhere between these two positions. For those addicts who have a singular diagnosis of addiction and no co-occurring psychiatric or health issues; then, medicines may not have a place. Most studies on the FDA approved relapse prevention medications for alcohol dependence (disulfiram, acamprosate, naltrexone) do show some improvement in relapse prevention, but only in the range of about thirty percent. With a life threatening disease, a thirty percent increase in short term sobriety is something that we take seriously. The studies are limited in terms of long term outcomes and use of these medications in combination with intensive inpatient treatment. One well designed randomized controlled trial with naltrexone failed to show a medication effect (Krystal, et al, NEJM Vol 345, No 24, 2001). Twelve step facilitation was used in Krystal’s study and at 13 weeks only 40% of patients had relapsed to drinking. We do believe it is the responsibility of the addiction treatment team to present this data to the patient and let the patient make an informed decision on whether to pursue this option or not.

The more rancorous conflicts come in treating possible psychiatric illnesses in active addiction and in recovery. Underlying the conflict is the difficulty in making an accurate diagnosis of a psychiatric disorder in either active addictions or early recovery. Several studies have shown that the validity of psychiatric testing is very suspect in active addiction and early recovery. Those with active addictions, early recovery, or withdrawal can present with signs and symptoms that resemble severe depression, bipolar disorder, schizophrenia, Attention Deficit Hyperactivity Disorder (ADHD) or other severe mental health problems. The resolution of this conflict is not easy, as over diagnosing and medicating is equally as dangerous as under diagnosing and not treating true psychiatric illnesses.

We recommend being very cautious and judicious in making any Axis I diagnosis in patients in active addiction or early recovery. The central nervous system and the body go through tremendous changes in active addiction and in early withdrawal and recovery. People may need several weeks or even months to stabilize. However; if valid diagnoses of psychiatric illnesses are made, then we proceed with medication management and support. We also stress that any Axis I diagnosis made at this stage should not be a lifelong diagnosis and should be reevaluated by a qualified physician after six to twelve months of healthy sobriety and recovery. We are firm with our recommendations to all of our patients to avoid all medicines that may hinder their recovery or increase their chances of relapse in the future, and are careful to only use cross tolerant medications during the detoxification phase. We do not recommend long term use of any medications that have activity in the reward pathway (i.e. benzodiazepines for anxiety or stimulants for ADHD). The opiate family can obviously not be avoided at all times by the chemically dependent patient. There may be situations where opiate use is recommended, such as post-op pain, myocardial infarctions, severe trauma, etc; but these must be limited in amount and used with great caution.

Medication management has a place side by side with intensive 12 step recovery to address the physical, mental, and spiritual aspects of this disease. This controversy is far from being resolved by the addiction treatment community. To advance the field and improve outcomes, we need more dialogue among professionals evaluating data in a non prejudiced or judgmental fashion