Are the "New" Medications for Addiction Effective & Safe? The answer: It depends.
by Eugene A. Degner, MD
I have seen massive changes in the field of addiction medicine (ADM) since I entered the treatment field in 1983. Some changes have been for the good of the patient and some have been very questionable.
When I was certified in Addiction Medicine, the focus was to help that patient get drug and alcohol free. We were taught that once a brain experienced addiction it was always susceptible to relapse, no matter how long a period of abstinence lasted. Because of that concept, patients were taken off all drugs that hinted of producing dependency, with the thought being that a “clean” brain was best able to avoid relapse (sometimes called “awakening the sleeping giant”). It appears to me that concept is now considered old-fashioned, archaic, and generally wrong.
Another major change in the ADM field has been in the area of co-morbidity. I vividly remember being told by several experts in the ADM field, at ADM conferences, that alcoholics and drug addicts when fully detoxed had the same percentages of mental health problems as the general population. The literature today reports that alcoholics and drug addicts have 60% to 75% co-morbidity. If that is true, it is easy to see why so many drugs are being used on recovering and non-recovering addicts.
I must confess my bias is very conservative. My personal, family, and many patient experiences over these last 25 years have convinced me the less medications used on recovering individuals, the better. Having said that, I still use a fair amount of medication for Detox, and in some cases, maintenance.
Obviously there is some co-morbidity that accompanies addictions; whether it is 60-75% is questionable, but surely some exists. So the use of anti-depressants, mood stabilizers, and drugs like the atypical anti-psychotics is appropriate and safe. Used for appropriate indications, I believe these medications can enhance the recovery process and if not used could very well hinder recovery.
I am often asked if the “new” medications for addiction are effective and safe. These “new” drugs include Campral, Vivitrol, and Buprenorphine (Subutex and Suboxone). Campral was released for use in this country about two years ago. Campral’s mechanism of action is to block receptor sites that cause craving for alcohol. We use a lot of Campral in our treatment facility and our private office. It is safe, relatively free of side effects, and helpful in many patients. Campral alone helps reduce the urge to drink, but does not take the place of the psycho-social changes needed to accomplish recovery from alcohol dependency.
Vivitrol is a new presentation of an old drug Naltrexone. Naltrexone, an opiate receptor blocker, was marketed as Revia. Revia came in a tablet form but through a different mechanism from Campral was designed to reduce alcohol cravings. There were a fair amount of side effects with Revia, so it was used sparingly. Vivitrol is an intramuscular (IM) form of Naltrexone, which is given once a month. Again, Naltrexone is a safe, non-addictive drug which has shown some promise and results in reducing alcohol ingestion. Campral and Vivitrol can be used together since they use different mechanisms of action.
Buprenorphine (Subutex, Suboxone) has been released and marketed for outpatient detoxification of opiates. Medical doctors must take an eight hour course to prescribe Buprenorphine and they are issued a special DEA number.
So far, my experience with Suboxone has been somewhat mixed. Suboxone is a partial opiate agonist. It is a very long-acting drug. When given at the proper place of withdrawal (W/D) it will stop W/D symptoms dramatically. Several short protocols were proposed, but most patients in the outpatient setting cannot or will not tolerate these short 7-10 day detoxes. We are instructed to encourage patients to engage in some form of psycho-social treatment but few patients follow through with this. We are presently attempting to set up in our office a trained therapist to try to fill this void.
Suboxone and Methadone share many characteristics. Suboxone without question is safer since overdoses, whether accidental or intentional, are virtually impossible. That is not true of Methadone. My greatest concern about Suboxone outpatient Detox is that, like Methadone, patients have a very, very difficult time getting all the way off the drug. They seem to tolerate low doses, but W/D symptoms hit when doses are further reduced and the patient tends to stall out. Our ultimate goal is always “drug free” but that appears to be very difficult to accomplish. My fear is this phenomenon will lead simply to Suboxone maintenance and the concept of full detoxification will be abandoned.
Where I have really found Suboxone to be the most help is in the Inpatient Detox unit.There patients are basically detoxed from opiates with high dose Clonidine. In most patients, there is a day or two in that process where they become quite uncomfortable and during those episodes we use small “touch” doses of Suboxone. Patients get excellent relief from this technique and do not get enough Suboxone to then have to withdraw from it. So Detox in our inpatient unit results in a drug free patient in most cases in 5-7 days.
Our goal in our private practice office and our chemical dependency unit for addicted patients is abstinence. To me, abstinence and a recovery program that works on body, mind and sprit is the key to a high quality of life. To me, to be drug free means more than “no drugs or alcohol in my body”. Drug free to me means, yes, abstinent of drug and alcohol, but free of all the “costs” of dependency: free of “Do I have enough?”, “Where can I get more?”, “How much does it cost?”, “Will I get arrested?”, “Can I pass my drug screen?”, “Will my liver be all right?”, “Will I ever be able to get off this stuff?”, and so on. I believe drug free means freedom.
Eugene A. Degner, MD serves as Medical Director of Memorial Hermann Prevention and Recovery Center in Houston, and is in Private Practice with Contemporary Medicine Associates. Dr. Degner is certified in Addiction Medicine by ASAM (American Society of Addiction Medicine) and is Board Certified in Family Medicine.