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Medications in the Treatment of Substance Use Disorders

July 15, 2011
by Christina M. Delos Reyes, MD
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It's Time to Overcome Pessimism About Successfully Treating Addictive Disorders

I. Introduction

A. SUDs as medical illnesses

Christina M. Delos Reyes, MD
Christina M. Delos Reyes, MD

Alcohol and other substance use disorders have been recognized by the American Medical Association (AMA) as diseases since the mid-1960s. Despite this fact, the treatment of substance use disorders has remained largely segregated to free-standing substance abuse treatment centers, which rarely employ physicians and other medical staff. At the same time, physicians in hospitals and outpatient settings have found it difficult to treat patients with substance use disorders because of a lack of knowledge, a lack of skills, and a lack of effective medications to treat this population. For example, prior to 1984, only two medications were approved for the treatment of any substance use disorders (methadone for opiate dependence in 1947 and disulfiram for alcohol dependence in 1951). Since 1984, several more medications have been approved for the treatment of addictive disorders.

Segregation of addiction treatment from mainstream medicine has had other negative effects. Doctors tend to treat only the medical and psychiatric consequences of substance use disorders instead of focusing on the primary illness of addiction. Likewise, many providers of primary chemical dependency treatment mistrust the medical establishment and are very skeptical about the role of medications to treat addictive disorders. Not surprisingly, doctors and chemical dependency providers have developed a pervasive therapeutic pessimism about successfully treating addictive disorders.

B. Bringing medication-assisted treatment into the addiction field

Now is the time to integrate medication-assisted treatment into the chemical dependency field. In the most recent decade, numerous medications have been developed to treat the primary signs and symptoms of addictive disorders. This paper will review the medications most commonly used in the treatment of addictive disorders. Medications are currently used for two broad purposes in the treatment of substance use disorders. The first reason to use medications is to treat the symptoms of withdrawal during the process of detoxification. The second reason to use medications is to prevent relapse and to enhance long-term recovery from substance use disorders.

C. Medications during detoxification-treating symptoms of withdrawal

Not all drugs of abuse require medication treatment of withdrawal. Medications are most often used for the treatment of alcohol withdrawal, opiate withdrawal, and nicotine withdrawal. During the process of alcohol withdrawal, a cross-tolerant medication such as a benzodiazepine or phenobarbital is used to prevent seizures and delirium tremens. During the process of opiate withdrawal, medications such as clonidine, methadone, buprenorphine, or tramadol can be used to lessen the acute symptoms of opiate withdrawal, including but not limited to agitation, anxiety, muscle aches, sweats, chills, nausea, vomiting and diarrhea. During the process of nicotine withdrawal, nicotine replacement therapy is helpful in decreasing the acute signs and symptoms that may be present.

D. Medications during rehabilitation-enhancing relapse prevention

Medications can be used to prevent relapse to alcohol and other drug use. The Food and Drug Administration (FDA) has approved medications to treat alcohol, opiate, and nicotine dependence. At the present time, there are no FDA-approved medications to treat stimulant, marijuana, or hallucinogen dependence.

II. Medications for alcohol dependence

Disulfiram (Antabuse) is an oral medication that works by blocking the enzyme that breaks down alcohol. Therefore, toxic metabolites such as acetaldehyde accumulate in the body, causing very unpleasant symptoms such as severe nausea and vomiting and facial flushing. Disulfiram works as a deterrent to drinking alcohol and is most successful if patients are motivated to use it, or are closely observed taking it on a regular basis.

Naltrexone (Revia or Trexan) is an oral medication that works by blocking the opiate receptor. It was initially approved for the treatment of opiate dependence, but was later found to be useful in decreasing cravings for alcohol and in reducing the severity of alcohol relapses. Naltrexone also comes in the form of a monthly injection (Vivitrol) that helps to increase treatment adherence.

Acamprosate (Campral) is an oral medication that works by stabilizing the glutamate and GABA neurotransmitter systems in the brain. It helps to decrease cravings for alcohol and it increases periods of complete abstinence from alcohol. Acamprosate must be taken two to three times per day and is metabolized by the kidneys.

Other medications such as topiramate, baclofen, and ondansetron are currently being studied for their usefulness in treating alcohol dependence, but they are not yet FDA-approved for this indication.

III. Medications for opiate dependence

Naltrexone (Revia or Trexan) is an oral medication that blocks the opiate receptor. Patients that are taking opiates will not feel the rewarding effects of the opiates as long as they are taking naltrexone. However, its usefulness is limited by non-adherence to the treatment regimen. Recently, the FDA approved injectable naltrexone (Vivitrol) for the treatment of opiate dependence.