“With medication assistance treatment (MAT), which is using a medicine to treat a disease, success rates are over 70 percent – 70 percent of people will be abstinent in one year.”
~ Raj Masih, the Potomac Highland Guild’s Substance Abuse Anti-Stigma Initiative
According to the National Center on Addiction and Substance, greater than 1 in 7 people in the United States age 12 and older have a Substance Use Disorder (SUD). But only about 10% of those in need will receive specialized professional treatment.
Much of the disparity between that need and having it met involves the various anti-addiction medications that are used as primary or adjunct therapies to support recovery from addiction. Simply put, these proven-to-be effective tools just aren’t being used as much as they should be.
Why Aren’t More Anti-Addiction Medications Being Properly Utilized?
“There is no other disease where approved medications are not provided to everyone who needs them. We used to consider people with mental illness inferior, even possessed. Scientific advances have combatted stigma around a wide variety of brain diseases, but not addiction.”
~ Dr. Kelly Clark, President of the American Society of Addiction Medicine
There are several reasons why the potential benefits of these medications aren’t being fully realized:
- Stigma – Even though addiction has been identified as a disease of the brain, there are still some people who attach a stigma to its sufferers. Alcoholics and drug addicts are often told that they are weak, selfish, or lacking in willpower.
How does this stigma translate into a shortage of care?
While only about 10% of people with an SUD get proper care, the treatment rate for other chronic diseases – diabetes, asthma, cancer, hypertension, etc. – is around 80%.
- Shortage of trained physicians – While there are over 900,000 doctors in the United States who can prescribe opioid painkillers, only about 32,000 – or roughly 3% – possess the additional training and special license required to legally dispense some of the medications used to combat addiction.
This makes finding an addiction doctor a major challenge, especially in rural areas.
Complicating matters is the fact that even after receiving that special license, these doctors are limited to the number of patients they can treat for addiction. This means often-lengthy waiting lists.
- Physician bias – Many primary physicians prefer not to treat patients with SUDS, finding them hard to deal with and disruptive in the waiting room.
- Rehab non-participation – Just 1 in 3 rehab facilities provide anti-addiction medications.
- Insurance coverage – Not all anti-addiction medications are covered by insurance, and there are often time-consuming pre-authorization requirements. Even then, dosages and length of treatment can be limited by some carriers.
Why Don’t More Rehab Facility Use Anti-Addiction Medications?
“…we can’t just base our service on philosophy, we have to look at the data and base our treatment on the best way to save lives.”
~ Dr. Marvin Seppala
The acceptance of addiction as a legitimate mental disorder is a relatively new concept. Too many mental health practitioners and rehab programs continue to treat patients the way they “always” have – relying solely on their own experience and established practices.
For example, for generations, the only approved path to recovery involved an abstinence-only approach. In other words, treatment providers balked at the idea that a substance abuser could truly recovery from their problem by subsequently using – or even becoming dependent – on yet another substance.
In some ways, this is a legitimate concern. Some anti-addiction medications are habit-forming and have a high potential for abuse. More importantly, a successful and safe return to a healthy and productive life is best supported by complete freedom from addictive substances.
However, today, the best rehab programs employ an evidence-based approach to treatment. And the evidence shows that the proper incorporation of Medication-Assisted Treatment (MAT) into a comprehensive plan of recovery works better than either detox or counseling alone.
Evidence-based programs take three things into account concerning MAT:
FIRST, there are newer medications that are safe, effective, non-addictive, and that present little to no potential for misuse. In other words, these medications DO support total abstinence.
SECOND, even when habit-forming or potentially-diverted medications must be used, it is possible to mitigate the dangers. When these anti-addiction medications are only prescribed over the short-term, stringently monitored, and most importantly, included as part of a more comprehensive treatment program, they can be an acceptable solution.
THIRD, when weighed against the established dangers of unchecked addiction – overdose, death, crime, disease, societal impact, etc. – the concept of “harm reduction” becomes an acceptable, if imperfect, step forward.
How are Medications Used to Treat Substance Abuse Disorders?
“(Anti-addiction medications) have been proven as the gold standard for really helping people recover… That makes a huge difference in folks coming forward and looking for treatment.”
~ Marlies Perez, Chief of the Substance Use Disorder Compliance Division, California Department of Health Care Services
The medications that are prescribed during recovery from an SUD can help in several ways:
- Withdrawal – Some medications can ease symptoms of withdrawal experienced during alcohol or drug detoxification. The Substance Abuse and Mental Health Services Administration estimates that medications are used in nearly 80% of detoxes.
This is important, because although DETOX IS NOT TREATMENT, it is critical for a smooth, safe, and successful recovery.
- Relapse prevention – Patients can use anti-addiction medications to reduce substance cravings and help restore normal brain function.
- Treatment for co-occurring disorders – Many substance abusers also struggle with comorbid mental illnesses such as anxiety, depression, PTSD, or bipolar disorder. Because these conditions can both worsen – and be worsened by – addictive disorders, simultaneous treatment should be part of any comprehensive recovery plan.
Types of Anti-Addiction Medications
There are several different classes of anti-addiction medications, each applicable to different treatment scenarios:
- Replacement Medications –Opioid Replacement Therapy (ORT) – also referred to as opioid substitution therapy or opioid maintenance therapy – is a kind of medication-assisted treatment for patients who are addicted to or dependent on opioid drugs such as heroin or prescription painkillers. During ORT, the abused opioid is replaced with a safer, less-euphoric, and longer-lasting opioid medication. ORT is an attempt to “manage” the addiction until the patient is ready to participate in a more comprehensive treatment program.
- Agonists –These are medications that attach themselves to the same receptors in the brain as the abused substance, thereby reducing cravings.
- Aversion Therapy – Some medications seek to prevent substance use by triggering painful or uncomfortable reactions whenever the substance is consumed.
Let’s take a look at the various medications used to treat different kinds of SUDS:
Date introduced: Europe-1989, FDA-2004
Brand names: Campral, also available as a generic
What You Need to Know: Acamprosate helps reduce alcohol cravings in patients who have already stopped drinking. It helps restore the brain’s neurochemical balance.
Special advantages: Acamprosate increases the number of patients who are able to completely abstain from alcohol as well as the total number of days without alcohol. Importantly, it has also been shown to help with the sleep disturbances that are common to people in recovery from alcohol addiction. Acamprosate is also the recommended medication for alcoholics already suffering from liver disease or damage.
Special disadvantages: Although acamprosate can help someone maintain their sobriety, it is not effective at helping that person become abstinent from alcohol. It is not recommended for someone suffering from kidney damage.
Dosage: Two 333 mg tablets, three times daily
Major Side Effects: The label warns of kidney failure, major depressive disorder, and suicidal behavior.
Date introduced: 1977
Brand names: Lioresal, Lioresal Intrathecal, Gablofen, Kemstro
What You Need to Know: Baclofen is a muscle relaxant and anti-spastic medication.
Special advantages: People taking baclofen for 12 weeks were more likely to be abstinent from alcohol (71% vs 29%). This medication also possesses antianxiety and sedative properties, both of which can be beneficial for recovery. Baclofen has virtually no abuse potential.
Special disadvantages: Baclofen is currently not approved by the FDA as an alcohol addiction treatment. However, it is very commonly prescribed “off-label” for this purpose.
Dosage: Day 1: 5 mg once per day, increasing to 10 mg three times a day by Day 7. If necessary, the dosage can be increased even more.
Major Side Effects: Abrupt discontinuation of baclofen can lead to withdrawal symptoms similar to that of alcohol or benzodiazepines.
Benzodiazepines (Alcohol, Benzodiazepines)
Date introduced: Approved in 1960
Brand names: Librium (chlordiazepoxide), Klonopin (clonazepam), and Valium (diazepam) are the long-acting benzodiazepines that are most-often prescribed for withdrawal.
What You Need to Know: “Benzos” are minor tranquilizers typically prescribed for anxiety, insomnia, or seizures.
Special advantages: Benzodiazepines are far less toxic than barbiturates, the sedatives they have largely replaced.
Special disadvantages: This class of medication is EXTREMELY habit-forming, making them major drugs of abuse. They are only considered safe over the short-term.
Dosage: A typical Valium regimen for alcohol withdrawal might initiate with 10 mg four times daily on Day 1, eventually tapering to 5 mg taken in the morning on Day 7.
Major Side Effects: When a person is dependent upon benzodiazepines, abrupt discontinuation can be extremely dangerous – even fatal. Benzo doses should always be gradually tapered under the close supervision of medical personnel.
Buprenorphine (Opioids, Possibly Cocaine)
Date introduced: 2002
Brand names: Belbuca, Buprenex, Butrans, Subutex
What You Need to Know: Buprenorphine is a longer-lasting opioid that binds to the brain’s opioid receptors and block the effects of other, more dangerous opioids. Because it is a “partial agonist”, it produces both less euphoria and less respiratory depression than the abused opioid.
Special advantages: “Bupe” has a “ceiling”—after a certain point, the effects of buprenorphine do not increase, regardless of dosage. This means that users cannot get high from ANY opioid.
Special disadvantages: Buprenorphine is an extremely tightly-controlled medication. In order to prescribe it, doctors must complete special additional training and obtain a special license. The federal government also limits the number of patients a buprenorphine doctor may treat.
Dosage: The medication regimen should begin once symptoms of withdrawal are observed.
Day 1: 8 mg sublingually once daily
Day 2: 16 mg sublingually once daily
The medication can be adjusted up or down by 2 mg or 4 mg increments, until reaching a level that suppresses withdrawal symptoms and allows the patient to continue treatment.
Target dose: 16 mg once daily, with an acceptable range of 4 mg to a maximum of 24 mg daily
Major Side Effects: When taken with another depressant such as alcohol, benzodiazepines, or other opioids, there is a significant risk of overdose.
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Date introduced: 2002
Brand names: Suboxone, Zubsolv
What You Need to Know: According to the US Institute on Drug Abuse, this combination medication is approved as a first-line treatment for opioid dependence. It is primarily recommended for opioid users who:
- Are socially stable
- Can comply with their medication schedule
- Are unable to go to a methadone clinic daily
- Have a job that prohibits taking sedating medications
Special advantages: Naloxone was added to buprenorphine as an abuse deterrent.
Special disadvantages: This medication can still be abused by injection or by crushing and snorting. Of special relevance, non-dependent users can still get high from sublingual use, which may subsequently lead to dependence.
Dosage: The target dose for maintenance treatment is 16 mg/4 mg taken sublingually once per day.
Major Side Effects: It is possible to become physically dependent on buprenorphine/naloxone.
Bupropion (Smoking, Possibly Cocaine)
Date introduced: Approved in 1974
Brand names: Wellbutrin, Zyban
What You Need to Know: Bupropion is a widely-prescribed antidepressant, but interestingly, its effectiveness as an anti-smoking medication is not due to its antidepressant properties. This medication reduces the severity of cravings for nicotine, and nicotine withdrawal symptoms.
Off-label, bupropion can significantly reduce cravings and depression during cocaine detoxification.
Special advantages: Bupropion causes less sleepiness, weight gain, and sexual dysfunction than other antidepressants. It is not considered a drug of abuse.
Special disadvantages: This medication should not be used by people with epilepsy, eating disorders, or who are using/experiencing withdrawal from either alcohol or benzodiazepines.
Dosage: Initial dose: 150 mg once daily for 3 days, increasing to 150 mg twice daily
Maintenance dose: 150 mg twice daily – this is the MAXIMUM dose
Duration of therapy: 7-12 weeks
Major Side Effects: Bupropion can increase the risk of epileptic seizures.
Date introduced: Patented in 1975
Brand names: Buspar, also available as a generic
What You Need to Know: Buspirone is an anti-anxiety drug that can also be prescribed to boost the effectiveness of antidepressants. This medication is at least as effective as a methadone taper at relieving the symptoms of opioid withdrawal.
Special advantages: Because it is neither a barbiturate nor a benzodiazepine, buspirone is considered to be much safer and is not classified as a drug of abuse. Additionally, it is not sedating, does not produce euphoria, does not affect motor function, and triggers no withdrawal symptoms.
Special disadvantages: This medication is not effective at treating withdrawal from alcohol, benzodiazepines, or barbiturates.
Dosage: In a study treating stabilized heroin addicts, the most effective dosage was 45 mg taken daily.
Major Side Effects: Buspirone should not be taken by people with diabetes, liver or kidney problems, or by those who take MAO inhibitors.
Calcium Carbimide (Alcohol)
Date introduced: 1955
Brand names: Temposil
What You Need to Know: Calcium carbamide is an alcohol aversion medication that interferes with the way alcohol is metabolized. If any alcohol is consumed, the person will experience a severely unpleasant reaction:
- Profuse sweating
- Throbbing headache
- Accelerated heartbeat
- Difficulty breathing
- Extreme nausea
- Copious vomiting
Special advantages: Calcium carbamide promotes “abstinence only” recovery. When incorporated as part of a comprehensive program that includes behavioral counseling, success rates are over 50%.
Special disadvantages: This medication does not relieve cravings for alcohol. Also, the reaction is triggered by ANY alcohol, even from personal hygiene or household products – cologne/perfume, sanitizer, deodorants, lotions, cleaners, air fresheners, etc. Because the required lifestyle changes are so extensive, compliance with the medication regimen is generally poor.
Dosage: 50 mg-100 mg every 12 hours. This medication should NEVER be administered to an intoxicated person.
Major Side Effects: Increases the patient’s white blood cell count.
Date introduced: Approved in 1968
Brand names: Tegretol
What You Need to Know: Carbamazepine is primarily prescribed for epilepsy and neuropathic pain.
Special advantages: This medication is especially effective for patients who have had unsuccessful attempts at alcohol detox in the past. Because it is not a benzodiazepine, it has no potential for abuse.
Special disadvantages: Carbamazepine cannot be used by pregnant women, because it may harm the fetus.
Dosage: For alcohol withdrawal, the effective dose for a 5-day taper is 600-800 mg, gradually reduced to 200 mg.
Major Side Effects: Carbamazepine can decrease the production of red blood cells, white blood cells and platelets. Use is also associated with an increased suicide risk.
Date introduced: 1932
Brand names: Dexedrine
What You Need to Know: “d-AMP” is a stimulant typically prescribed to treat Attention Deficit Hyperactivity Disorder (ADHD) or narcolepsy.
Special advantages: After an 8-week study, researchers determined that this medication reduces cravings and withdrawal symptoms associated with methamphetamine use. d-AMP is as effective at reducing intravenous meth use as methadone is at reducing IV heroin use.
Special disadvantages: Dextroamphetamine has a high potential for abuse and addiction.
Dosage: The study administered 60 mg of dextroamphetamine to participants daily.
Major Side Effects: Even at therapeutic doses, dextroamphetamine can cause rapid heartbeat and affect both blood flow and pressure.
Disulfiram (Alcohol, Possibly Cocaine)
Date introduced: 1951, making it the first medication approved for alcohol addiction.
Brand names: Antabuse
What You Need to Know: Disulfiram is an alcohol aversion medication that works by producing an immediate and severe reaction if alcohol is consumed. In as little as 5 minutes after drinking, a disulfiram patient experiences:
- Flushed skin
- Shortness of breath
- Rapid heartbeat
- Throbbing headache
- Severe nausea
- Uncontrollable vomiting
Special advantages: Disulfiram promotes an “abstinence-only” lifestyle – it works if ANY alcohol has been consumed within the previous 12 hours. The longer it is taken, the stronger the reaction is.
Special disadvantages: Disulfiram does not reduce cravings for alcohol. Because this medication requires extreme lifestyle changes – to the point of avoiding personal hygiene and household products containing alcohol – compliance is generally poor.
Dosage: 250 mg, once daily
Major Side Effects: Headache, metallic taste, decreased libido
Gabapentin (Alcohol, General Substance Abuse)
Date introduced: 1993
Brand names: Neurontin, Gabarone, Gralise, Fanatrex, Horizant
What You Need to Know: Gabapentin is a non-opioid medication prescribed for a wide variety of conditions, including:
- Diabetic neuropathy
- Post-surgical pain
- Multiple sclerosis pain and spasticity
- Itching due to kidney failure
- Restless leg syndrome
- Hot flashes
- Involuntary eye movement
- Non-seizure alcohol withdrawal
- Secondary treatment for Substance Use Disorders
Special advantages: At higher doses, gabapentin increases the days that patients are able to completely abstain from alcohol and decrease the incidence of heavy drinking on non-abstinent days.
Although it is an effective pain medication, gabapentin is not an opioid and has a much lower potential for abuse.
Special disadvantages: Lower potential does not mean NO potential. 2 out of every 3 people with a gabapentin prescription abuse it recreationally or in an attempt to self-medicate.
Dosage: The most successful trial gave participants 1800 mg daily.
Major Side Effects: The FDA has warned that gabapentin use results in increased suicidal thoughts and behaviors.
Date introduced: 1947
Brand names: Dolophine, Methadose
What You Need to Know: Methadone is an opioid used during ORT, in this case called Methadone Maintenance Therapy (MMT).
Special advantages: As the most-common first-line treatment prescribed for opioid addiction, methadone is available in over 700 clinics across the country. When utilized as part of a comprehensive and individualized treatment plan, 67% of MMT clients are able to abstain from illicit opioid use, and up to 95% are able to curb use.
Special disadvantages: Methadone is powerfully-addictive and is very frequently abused. It also carries a high risk of overdose. In fact, methadone accounts for 40% of all single-drug prescription overdose deaths—DOUBLE the deaths attributed to any other single opioid painkiller.
The initial dose of methadone should be given while withdrawal symptoms are present.
Day 1: Initial dose: 20-30 mg orally. 30 mg is the MAXIMUM initial dose.
After 2-4 hours, an additional 5 to 10 mg may be given orally if withdrawal symptoms have not been reduced or if symptoms reappear. 40 mg is the MAXIMUM Day 1 dose.
Week 1: The dose may be adjusted to control withdrawal symptoms. CAUTION – during the first several days of dosing, methadone levels will accumulate.
Opioid maintenance: There are 4 dosing goals:
- Prevent opioid withdrawal
- Reduce drug cravings
- Block the euphoric effects of illicit use
- Ensure patient safety from sedating effects
The target dose range is 80 to 120 mg a day. The success rate is tied to higher doses.
- Patients receiving less than 46 mg are 5 times more likely to use heroin as those on higher doses.
- Patients receiving more than 80 mg are one-fourth as likely to use heroin as those who receive less than 60 mg.
Major Side Effects: Dependence, withdrawal, respiratory depression – especially when used for pain.
Methylphenidate (Methamphetamine, Cocaine)
Date introduced: 1955
Brand names: Ritalin, Concerta, Aptensio, Biphentin, Daytrana, Equasym, Medikinet, Metadate, Methylin, QuilliChew, Quillivant
What You Need to Know: Methylphenidate is a central nervous system stimulant typically prescribed for ADHD or narcolepsy. United States uses 80% of the world’s supply.
Special advantages: Researchers at Stony Brook University in New York discovered that a single dose of methylphenidate normalizes those brain pathways that have been affected by chronic cocaine abuse. Of special relevance, methylphenidate’s uptake within the brain is slower than that of cocaine, which means the patient can avoid the euphoria and resultant cravings. In this respect, methylphenidate acts like ORT medications.
Special disadvantages: At higher-than-normal doses, methylphenidate has a moderate potential for recreational use.
Dosage: During the Stony Brook University study, participants were given 20 mg of methylphenidate.
Major Side Effects: Appetite suppression, weight loss, restlessness.
Date introduced: 1996
Brand names: Remeron, also available as a generic
What You Need to Know: Mirtazapine is typically prescribed as an antidepressant, but it also has a number of off-label uses:
- Anxiety disorders
- Panic disorder
- Obsessive-compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Nausea and vomiting
- Low appetite
Special advantages: In a 2011 study, mirtazapine significantly reduced methamphetamine use among active users. Significantly, there was also a decrease in risky sexual behaviors, even when medication compliance was low.
In an earlier 2010 study, the administration of mirtazapine cut cue-related methamphetamine seeking among test animals by 50%.
Special disadvantages: Like all antidepressants, it takes approximately a week of dosing for the benefits to manifest.
Dosage: During the 2011 study, participants were given 30 mg of mirtazapine.
Major Side Effects: Mirtazapine increases the risk of suicidal thoughts and behaviors.
Brand names: Provogil, also available as a generic
What You Need to Know: Modafinil is a wakefulness-promoting medication typically dispensed for narcolepsy or hypersomnia. Off-label, it is also used to treat fatigue, depression, cerebral palsy, Parkinson’s disease, and fibromyalgia. The United States Air Force has approved modafinil as a “go pill” for fatigue management.
Special advantages: A 2009 study concluded that modafinil was effective at reducing cocaine cravings and increases the number of non-use days among active cocaine users.
Special disadvantages: Although the abuse potential is very rare, discontinuation of modafinil can trigger withdrawal symptoms.
Dosage: During the study, the effective doses were 200 mg and 400 mg, given daily.
Major Side Effects: Headaches – 33%, Nausea – 11%
Date introduced: Approved in the United States in 1995 as an antidote for opioid overdose. Discontinued in 2008 due to poor sales. The pill form used to treat alcohol addiction is not sold in the US.
Brand names: Selincro
What You Need to Know: Nalmefene is an opioid agonist used to counteract the respiratory depression seen in opioid overdose. It is useful for reversing overdoses from long-lasting, opioids such as methadone.
Special advantages: This medication is effective at reducing alcohol consumption, resulting in:
- Fewer drinking days
- Fewer “heavy” drinking days
- Daily alcohol consumption
There are two special considerations concerning nalmefene:
FIRST, it is often prescribed for patients with a drinking problem who don’t want to completely abstain from alcohol.
SECOND, it can be taken on an “as needed” basis. Specifically, a patient can take nalmefene on those days when they feel they are at higher risk of drinking.
Special disadvantages: Mere “reduction” in alcohol consumption is not considered a safe or stable long-term objective. The medication’s own label says that it “should only be prescribed in conjunction with continuous psychological support”.
Dosage: One 18 mg dose daily, taken “as needed”.
Major Side Effects: Nalmefene should not be used by patients in need of alcohol detox or who have a recent history of alcohol withdrawal syndrome.
Date introduced: Patented in 1961, approved for opioid overdose in 1971
Brand names: Narcan, Evzio
What You Need to Know: Naloxone is an emergency medication given to reverse opioid overdoses.
Special advantages: In most areas, naloxone is available without a prescription. It is simple to administer, and it works almost immediately.
Although naloxone is not a “treatment” drug, surviving the close call of an overdose can compel an opioid addict to finally seek treatment.
Special disadvantages: Naloxone has a short half-life, so multiple administrations may be necessary during overdoses involving longer-lasting opioids. Also, naloxone is ineffective during overdoses from other substances.
Sadly, the expanded availability of naloxone has created a subculture of drug addicts. Some abusers will intentionally overdose, knowing that a friend is standing by, ready to revive them.
Dosage: When given intravenously, the dosage is .4 to 2 mg given every 2-3 minutes as needed, with a reassessment at 10 mg.
Major Side Effects: In people with opioids in their system, naloxone immediately sends them into severe opioid withdrawal.
Naltrexone (Alcohol, Opioids, Cocaine)
Date introduced: Created in 1965, approved for medical use in 1984
Brand names: ReVia, Vivitrol
What You Need to Know: Naltrexone is a medication that is used to treat both opioid AND alcohol dependence. Whether given orally (ReVia) or via injection (Vivitrol), naltrexone totally blocks the effects of alcohol or any opioid. In other words, the user does not experience the pleasurable effects. It also reduces cravings for either opioids or cocaine.
Special advantages: Because naltrexone is NOT an opioid, it has several advantages over buprenorphine medications or methadone:
- There is no risk of dependence or addiction.
- It has no potential for abuse.
- Unlike methadone, ReVia is available as a take-home prescription.
- Unlike buprenorphine, ANY physician can prescribe naltrexone.
- Physician-administered Vivitrol injections are only needed once a month.
Naltrexone is extremely effective. Compared to counseling patients given a placebo, individuals receiving counseling and naltrexone:
- Have a higher rate of opioid-free weeks
- Experience fewer cravings
- Are less likely to relapse
- Remain in treatment longer
Special disadvantages: There are three main concerns that limit the widespread use of naltrexone:
- FIRST, patients must have gone through detox and remained opioid-free for up to 14 days before taking naltrexone.
- SECOND, while taking the medication, patients cannot use ANY opioid, including legitimately-prescribed painkillers.
- THIRD, Vivitrol injections can be expensive if not covered by insurance – up to $1500 apiece.
Dosage: ReVia – for alcohol dependence – 50 mg, once daily; for opioid dependence – 25 mg for the initial dose, and if no withdrawal symptoms present, then 50 mg once daily thereafter
Vivitrol – 380 mg once every 4 weeks
Major Side Effects: Use of ANY opioids during or within 2 weeks prior to taking naltrexone can trigger opioid withdrawal symptoms.
Date introduced: First isolated from tobacco in 1828
Brand names: Nicoderm CQ, Nicorette, Leader Nicotine Polacrilex, Nicotrol Inhaler
What You Need to Know: Nicotine is a stimulant found naturally in tobacco. Paradoxically, users report both increased alertness and sharpness AND greater relaxation and calmness.
Special advantages: When used in nicotine replacement products – lozenges, patches, inhalers, etc. – nicotine is an effective way to quit smoking.
Special disadvantages: Nicotine is considered one of the world’s most-addictive drugs. Withdrawal symptoms peak within the first few days and can persist for several weeks.
Dosage: For people who smoke their first cigarette within 30 minutes of waiting, the dosage is 4 mg. For those who wait longer than 30 minutes to smoke, the dosage is 2 mg.
The regimen is roughly the same for both nicotine gum and lozenges:
Weeks 1-6: Every 1 to 2 hours
Weeks 7-9: Every 2 to 4 hours
Weeks 10-12: Every 4 to 8 hours
Major Side Effects: Nicotine is involved in plaque development and clot formation. It also promotes tumor growth.
Phenobarbital (Alcohol and Benzodiazepine Withdrawal)
Date introduced: 1912
Brand names: Luminal, many others
What You Need to Know: Phenobarbital is the oldest commonly-used anti-seizure medication, typically prescribed for epilepsy, insomnia, and anxiety.
Special advantages: This medication is an effective way to control tremors and convulsions during withdrawal from alcohol or benzodiazepines. It also helps reduce anxiety during detoxification.
Special disadvantages: Phenobarbital is a highly-addictive central nervous system depressant. It is so potent that it is frequently used during lethal injection executions and in physician-assisted suicides.
Dosage: The initial dose should be 10 mg per kilogram of patient body weight, administered intravenously. Then, the physician should wait 30 minutes for the medication to take full effect. If necessary, either 130 mg or 260 mg can be given every 30 minutes as needed, depending upon the severity of symptoms. There is no defined maximum dose of phenobarbital – it depends on the clinical effect.
Major Side Effects: At overdose levels, phenobarbital slows all bodily functions, often to the point of death.
Propranolol (Alcohol, Cocaine)
Date introduced: 1964
Brand names: Inderal, InnoPran
What You Need to Know: Propranolol is a beta-blocker used to treat high blood pressure. It also shows promise as a treatment for performance anxiety and PTSD.
Special advantages: Researchers at the University of Cambridge believe that propranolol can be used to alter the emotional memory of cue-related triggers that drive compulsive drinking or drug-seeking.
Special disadvantages: The use of propranolol to treat addictive disorders is still in the research stage.
Dosage: At this point, the only studies have been conducted with laboratory rats.
Major Side Effects: Propranolol overdose is associated with seizures and cardiac arrest. Patients struggling with depression or suicidal thoughts are cautioned against using this medication.
Date introduced: 1997
Brand names: Exelon
What You Need to Know: Rivastigmine is used to treat dementia due to Alzheimer’s or Parkinson’s disease.
Special advantages: A 2012 study suggests that methamphetamine abusers who are given rivastigmine experience less subjective positive effects during use.
Special disadvantages: The study also indicated that use of the medication did not alter the number of times that participants chose to use meth.
Dosage: During the 8-day study, participants were given up to 6 mg of rivastigmine daily. However, due to the results, researchers concluded that higher dosages and longer periods were needed.
Major Side Effects: Nausea, vomiting, decreased appetite, and weight loss are all side effects. It should also be noted that rivastigmine is associated with a higher frequency of deaths than other similar drugs.
Date introduced: Discovered in 1988, launched in the US in 1998
Brand names: Gabitril
What You Need to Know: Tiagabine is an anticonvulsant medication, typically prescribed for the treatment of epilepsy.
Special advantages: A 2002 study concluded that high-dose tiagabine treatment resulted in less cocaine use among participants.
Special disadvantages: The risk of side-effects is magnified at dosages over 8 mg per day.
Dosage: In the 2012 study, 24 mg of tiagabine per day were dispensed.
Major Side Effects: Among patients without epilepsy, the use of this medication can trigger seizures, especially among those taking other medications that lower the seizure threshold – alcohol, amphetamines, or alcohol, for example.
Topirimate (Alcohol, Cocaine)
Date introduced: 1996
Brand names: Topamax
What You Need to Know: Topiramate is an anticonvulsant medication that is typically prescribed for epilepsy or for the treatment of migraine headaches.
Special advantages: A 2013 study concluded that topiramate use resulted in an almost tripled proportion of cocaine non-use days and urinary cocaine-free weeks, compared to a placebo.
Even more encouraging, multiple studies have determined topiramate’s efficacy as a treatment for alcohol. Patients given this medication report:
- Taking almost 3 fewer drinks per day
- Reducing their “heavy” drinking days by nearly 28%
- Increasing their number of alcohol-abstinent days by over 26%
Special disadvantages: Alcohol abuse while on topiramate may induce seizures.
Dosage: In most trials, the effective dose was determined to be 300 mg per day.
Major Side Effects: This medication can interfere with internal heat regulation.
Varenicline (Smoking, Alcohol)
Date introduced: 2006
Brand names: Chantix, Champix
What You Need to Know: Varenicline is a prescription medication primarily given as a treatment for nicotine addiction.
Special advantages: Varenicline is the most-effective tobacco-cessation medication. In fact, patients given this medication are three times more likely to stop smoking than those receiving a placebo.
It also shows promise for the treatment of problematic alcohol use. In a 2013 study, participants receiving varenicline were able to cut their days of “heavy” drinking by 22%.
Special disadvantages: Because varenicline directly affects the brain’s chemistry to reduce cravings, users are cautioned against changes in mood or behavior.
Dosage: Days 1-3: .5 mg, taken once daily
Days 4-7: .5 mg, taken twice daily
Day 8 through the end of treatment: 1 mg, taken twice daily
Smoking cessation treatment should last a total of 24 weeks.
Major Side Effects: 30% of patients taking varenicline experience nausea.
Other Helpful Medications
In addition to medications that specifically help with cravings, there are a number of other prescription remedies that can support a smoother transition to sobriety.
- Clonidine (Catapres, Kapvay)– Helps with opioid withdrawal by lowering blood pressure and heart rate. 85% of rehab patients given both naltrexone and clonidine successfully complete treatment.
- Chlorpromazine (Largactil, Thorazine) – Alleviates anxiety and restlessness, and may also help with nausea and vomiting.
- Folic Acid (Vitamin B9) – Folic acid replenishment can help ease depression during alcohol recovery.
- Haloperidol (Haldol) – This medication is prescribed as a treatment for the psychosis and hallucinations that manifest during alcohol withdrawal.
- Imipramine (Tofranil) – This prescription medication helps with depression by boosting levels of norepinephrine and serotonin.
- Methocarbamol (Robaxin) – This muscle relaxant has a low abuse potential, and helps with the spasms frequently experienced during withdrawal.
- Pregabalin (Lyrica) – Treats the anxiety and seizures that occur during alcohol withdrawal.
- Pyridoxine (Vitamin B6) – Replenishing this vitamin helps restore the normal formation of neurotransmitters.
- Thiamine (Vitamin B1) – Excessive alcohol consumption directly interferes with thiamine uptake within the gastrointestinal tract. This deficiency can lead to Wernicke–Korsakoff syndrome (WKS), a condition caused by alcohol-related brain damage. This is considered a medical emergency, and the administration of thiamine is the first-line treatment.
Is an Anti-Addiction Vaccine Possible?
“The concept of addiction vaccines is if you can prevent the addictive molecule from reaching the brain, you won’t get the high and you’ll stop using.”
~ Ron Crystal, Weill Cornell Medical College
With all of the advances that further our understanding of the disease of addiction, it is tempting to believe that a cure is just around the corner. Because there are so many factors that contribute to the development of an SUD, such a complete remedy is unlikely.
To be clear – there is no “magic pill” that will instantly and permanently restore normal brain chemistry, eliminate cravings, alter vulnerable genetics, and, most of all, resolve all of the socioeconomic factors that played a role in the progression of the disease.
MAT is only one of the many tools that can be utilized to craft a successful and enduring recovery from drug or alcohol addiction. On their own, pharmaceutical options are not particularly effective at reducing or eliminating problematic substance use.
However, when used in combination with other evidence-based treatment strategies – behavioral counseling, peer group therapy, nutritional guidance, etc. – these anti-addiction medications can strongly support safety, stability, serenity, and sobriety.