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The medication holdouts

May 15, 2011
by Alison Knopf
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Some experts charge centers that avoid drug treatments with shunning science and ethics

Disulfiram, naltrexone, acamprosate, methadone, buprenorphine-the medications approved to treat addiction literally can be counted on the fingers of one hand. Although they have been available for at least 10 years (buprenorphine) and in some cases more than 50 (methadone), these medications have been shunned by many addiction treatment clinicians, despite evidence that these treatments could help their patients.

Nowhere else in medicine are the people who treat a condition so suspicious of the very medications designed to help the condition in which they specialize. The situation is improving, but not fast enough for many, and advocates of medication-assisted treatment are speaking out.

“It's unethical not to use medications,” says Charles O'Brien, MD, PhD, Kenneth Appel Professor in the Department of Psychiatry at the University of Pennsylvania and one of the country's top clinical researchers in addiction treatment. “If you're discouraging people from taking medications, you are behaving in an unethical way; you are depriving your patients of a way to turn themselves around. Just because you don't like it doesn't mean you have to keep your patients away from it.”

O'Brien adds, “This is a subject that I feel very strongly about,” saying he has “stopped pussyfooting around” and doesn't care who he offends in his speeches. “There is a long history of rigidity about refusing to use medications.”

O'Brien lays much of the blame for this at the foot of organized medicine, saying 12-Step programs and Alcoholics Anonymous (AA) were founded because the medical profession traditionally ignored alcoholism. But by the late 1960s and 1970s “we got science involved,” he said. Many in the treatment field, however, haven't caught up.

And to the extent that the treatment community is catching up, it is still largely leaving buprenorphine out of the picture, and not even considering methadone, the province of specialty opioid treatment programs. These two medications are proven to help keep opioid-addicted patients in recovery, but many highly respected treatment programs refuse to consider them, even though the prevalence of prescription opioid addiction is dramatically increasing.

Outlook at Betty Ford

The only addiction treatment medication used at the Betty Ford Center, the nationally renowned licensed addiction treatment hospital in Rancho Mirage, Calif., is buprenorphine, and it is used only for detoxifying opioid-dependent patients, says James Golden, MD, director of inpatient services. “We like them to leave the center taking no medications,” says Golden.

He concedes that the non-abuseable addiction treatment medications-acamprosate, oral naltrexone and the injectable naltrexone formulation Vivitrol-“can be used with some success in clinical subsets.” But not at the Betty Ford Center-at least not “at this time,” says Golden.

There are several reasons for this, he explains. The first is that these are agents that need to be monitored on an ongoing basis by qualified addiction physicians, he says, noting that many patients come to the Betty Ford Center from long distances. “If I were to start an opioid-dependent patient on a drug such as naltrexone as a blocking agent, I would want the person following that patient to be reliable, to be maintaining the same kind of quality we have here,” Golden says. “We're not always certain that will happen.”

Patients are, of course, free to obtain medication from a physician after completing treatment at the Betty Ford Center, but this would occur on the patient's own initiative.

Golden admits that he is “not in a good position to give good information on Vivitrol” because he doesn't use it on patients. “But I see what the evidence is, so I have to say that when these patients transition out, if they're eligible for this treatment, I don't have a problem with it,” he says.

Golden adds that many patients simply choose not to be on any medications. “When they come here they may be on benzodiazepines, mood stabilizers and opioids,” he says. “Getting them off these medications is a challenge, and when they're done they really don't want to be on any drugs anymore,” even an antidepressant. “The patient is the one who says, ‘I want to get off these things,’” he says.

Finally, many patients who come to the Betty Ford Center have had multiple relapses, says Golden. “I see some patients who tried naltrexone and drank through it,” he says. “I know the studies showed that it decreased heavy drinking days, and it has helped some people. But the ones we see here are the ones who were not successful.”

Golden says that mood disorders and comorbid medical conditions are treated with medications at the Betty Ford Center. But he tries to discourage patients from medications that are not necessary. For example, insomnia is a problem for many patients, and they might request sleeping medication. “I ask them, ‘Do you really want to be looking for a pill every night to go to sleep?’” he says.

Change at Hazelden

Another treatment program that has a history of not using medications, the Center City, Minn.-based Hazelden, now uses naltrexone, acamprosate and disulfiram (Antabuse), says medical director Omar Manejwala, MD.

“We've changed our practices,” says Manejwala, who joined Hazelden last year. “Every single alcoholic is offered either naltrexone or acamprosate at the admitting physical.” Those who decline are given another opportunity at their next physical. In addition, counselors may recommend that patients talk to the physician about medications.

“Acamprosate and naltrexone improve outcomes, and we use them because we know they work,” says Manejwala. There are no philosophical objections to those medications, even among counseling staff, he says. Typically, naltrexone is used over acamprosate at Hazelden.