Medication-assisted Treatment
Definition: Medication-assisted treatment is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. Medication assisted treatment is clinically driven with a focus on individualized patient care.
Pro's and Con's: Traditionally, addiction treatment has been based residential or outpatient "rehab" with support group attendance or on long term treatment in a "therapeutic community" setting. Unfortunately, many are unable to refrain from drinking or using drugs despite treatment. For such individuals, adding medication to counseling and support group participation may significantly improve their chances of remaining abstinent. The FDA has approved the use of medications to treat opioid dependence and alcohol dependence. Addiction specialists do prescribe medications "off label", but research is limited.
Both buprenorphine and methadone are effective treatments for opioid dependence, but both are also potent opioids that attach to and stimulate receptors with possible long term affects on brain substrates. Some addicts clearly need these medications, while others would be better served by trying medication-free treatment or by combining counseling with time-limited medication treatment. Others however, especially those with a long history of IV heroin use, may need medication for many years. Individuals treatment with medication should not be discriminated against in support group settings. Recovery requires abstinence from illegal drug or alcohol use. When medication is used properly, recovery is not only possible, it may be more likely. Read more about recovery.
Unfortunately, many addicts and some doctors view medication alone as treatment, rather than as one part of comprehensive approach. Some addicts receiving medications have never participated in any formal treatment. Medication alone is not treatment.
Buprenorphine: Buprenorphine (Suboxone TM, Subutex TM) is an opioid partial agonist. This means that, although buprenorphine is an opioid, its maximal effects are less than those of full agonists like heroin and methadone, so it has a low risk of overdose. Buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. Buprenorphine is tightly bound the he opioid receptor, so it can block the effects of full opioid agonists and can precipitate withdrawal symptoms if administered to an opioid-addicted individual while a full agonist is in the bloodstream. Buprenorphine has not well absorbed when swallowed but better absorbed when place under the tongue. Formulations for opioid addiction treatment are in the form of sublingual (i.e. under tongue) tablets and dissolvable film.
Many clinical studies have demonstrated the effectiveness of buprenorphine in treating opioid dependence. About as effect as methadone, this medication has the advantage of being prescribed from the office of a qualified physician. Any physician may take an 8-hour course and become qualified.
Almost all of the research regarding buprenorphine is based on shorter-term studies involving heroin addicts-- as similar population for which methadone is intended. There are now studies comparing traditional "drug-free" programs for patients with fairly new onset of addiction or who were dependent on lower doses of prescription opioids (e.g. Percocet TM). Many such patients have been maintained on buprenorphine for years and experience difficulty in "tapering off" the medication, even when prescribed in very low doses (e.g. 2 mg/d). Proper patient selection and the use of appropriate counseling services are important aspect of medication-assisted treatment with buprenorphine. Unfortunately, buprenorphine treatment can be expensive, even with a prescription plan, as most treating physicians do not accept insurance payment for office visit. Treatment is unaffordable for many.
Read more about buprenorphine.
Methadone: Methadone is a synthetic opioid that blocks the effects of heroin and other prescription drugs containing opiates. Used successfully for more than 40 years, methadone has been shown to eliminate withdrawal symptoms and relieve drug cravings from heroin and prescription opiate medications. Although often criticized, studies show that methadone saves lives by reducing infections (e.g. HIV) and heroin overdoses while also decreasing illegal drug-related activities. One major drawback to methadone treatment is the need to attend clinics to receive medication. Often these clinics are in the same neighborhoods where addicts are used to going to buy drugs--a trigger for relapse. One advantage to methadone treatment is lower cost when compared to buprenorphine.
Naltrexone: Naltrexone is an opioid blocker that is FDA approved for the treatment of alcohol dependence and opioid dependence. It is available as a daily oral medication (ReVia TM) or as a once a month injection (Vivitrol TM). The latter has the advantage of ensuring adherence to treatment, but the disadvantage that opioids cannot easily be used to treat pain in an emergency situation since the receptors are blocked.
Studies have shown the naltrexone dose reduce alcohol cravings for some, but not all individuals; genetics may play an important role. Although the exact mechanism responsible for the reduction in alcohol consumption observed with treatment is not entirely understood, studies suggests that occupation of the opioid receptors results in the blockade of the neurotransmitters in the brain that are believed to be involved with alcohol dependence.
As an opioid antagonist (blocker), naltrexone is used in the treatment of opioid dependence. It binds to opioid receptors, but instead of activating the receptors, it effectively blocks them. This medication must be used in conjunction with counselor. Addicts, frustrated that they cannot get "high" on opioids, may turn to other drugs. Another drawback to treatment is the fact that patients having received this treatment may be more susceptible to accidental overdose once the medication leaves the body since the opioid receptor has been blocked and becomes more sensitive to "usual" doses an addict might consume.
Acamprosate: Acamprosate (Campral TM) calcium is FDA-approved for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. The medication appears to be most useful in the weeks or months after detoxification. Acamprosate reduces the physical and emotional discomfort (e.g. sweating, anxiety, sleep disturbances) many people feel after they've stopped drinking which makes it easier for them not to drink after the immediate withdrawal period.
Medication Assisted Treatment for Smoking: Because smoking cigarettes is a legal activity, medications to treat addiction are often overlooked when considering the topic of medication-assisted addiction treatments.Medications used to treat nicotine addiction include varenicline (Chantix TM), bupropion (Zyban TM), nicotine patches, gum, nasal spray, inhalers, and gum. Each of these medications works best when combined with a behavioral treatment.