TUCSON, ARIZ. – Antiaddiction medications are becoming safer, more effective, and less prone to cause relapse, Dr. Michael E. Scott told clinicians at a psychopharmacology conference sponsored by the University of Arizona.
Not all patients remain abstinent on the new medications targeting neurotransmitters, but relapses tend to be shorter and less frequent, said Dr. Scott, medical director of the Sierra Tucson treatment center and a professor at the University of Arizona, Tucson.
“Success can be harm reduction, improvement in quality of life, and decrease in relapse severity,” he said, urging greater use of pharmacotherapy.
Patient selection and education are important, according to Dr. Scott. Compliance can be a problem, and objections from addiction professionals committed to abstinence programs as well as from some family members must be addressed.
“A medication is not the same as a drug. … A medication is a therapeutic thing, and education is important. The patient needs to know the difference,” he said, adding, “Those early in recovery are less likely to understand medication. Those later in recovery are at greater risk of relapse. You need to know where they are.”
Alcohol Withdrawal
Dr. Scott favored benzodiazepines as the cheapest, safest, most effective therapies for alcohol withdrawal. Four drugs have been approved for treatment: disulfiram (Antabuse), naltrexone (ReVia), acamprosate (Campral), and naltrexone IM (Vivitrol).
Disulfiram works best in patients who are motivated, intelligent, and not impulsive, according to Dr. Scott. He said evidence does not support its use as a single agent to promote abstinence but suggests it can reduce drinking days and works well with cognitive-behavioral therapy. He gives it to people in recovery programs.
Studies have shown oral naltrexone (approved for alcohol and opiate dependence) can delay relapses and reduce heavy drinking. Compliance is a major problem, however. He called it abysmal and suggested the best candidates for naltrexone therapy are patients mandated to treatment–for example, airline pilots and physicians in recovery.
Intramuscular naltrexone received U.S. Food and Drug Administration approval for alcohol dependence in 2006. Dr. Scott said physicians are still learning how to use it, but the once-a-month injections make compliance less of an issue. Patient selection is complicated, he noted, in that naltrexone IV has an extensive list of serious side effects, including suicidality and depression.
Compliance also is an issue with acamprosate, he continued, calling its three-times-a-day dosing requirement a fantasy. “It is too difficult a challenge for patients who are compliance-poor to begin with,” he said.
Acamprosate seems to promote abstinence, however, and has been shown to work well with naltrexone. “I think we are going to find the combination is better,” Dr. Scott said. “I think it's the trend where polypharmacy of addiction is going to be the norm rather than the exception.”
Opiate Detoxification
There's no clear choice of opiate detoxification regimen, according to Dr. Scott. Buprenorphine is a new option that only physicians can prescribe and only if they are licensed after taking a 1-day training program. “Even if you are not interested in addiction medicine, you do get addicts and opiate dependents in your practice,” he said, encouraging physicians to become licensed.
He discouraged another new approach, however: rapid/ultrarapid detoxification in which naloxone and naltrexone are administered under general anesthesia. “This is not a life-threatening illness. You don't want to kill your patients,” he said.
Treatment options include naltrexone, nalmefene (Revex), methadone, levo-alpha-acetylmethadol (LAAM), and buprenorphine. Dr. Scott said to make sure a patient is opiate-free before starting naltrexone or nalmefene, and he warned again that compliance is a major obstacle. Methadone is effective, he said, but LAAM has received a black box warning and is not recommended.
Buprenorphine is available by itself as Subutex or in combination with naloxone as Suboxone. Dr. Scott said both are effective but Suboxone can precipitate withdrawal and should not be used in pregnant women. Buprenorphine should not be used with benzodiazepine; the combination can be fatal.
Helping Smokers
Nicotine replacement, bupropion (Zyban), nortriptyline, and clonidine can help 1 more person out of 14 to quit smoking–an absolute benefit of 7%, according to Dr. Scott. Clonidine has serious side effects, however, and he suggested nicotine replacement products might be underdosed.
Dr. Scott said a newly approved medication called varenicline (Chantix) might be more effective. “Patients seem to like it. It is fairly easy to take.”
A medication is not the same as a drug, and the patient needs to know the difference. DR. SCOTT