Medications used in Treatment of Alcohol and Drug Use Disorders Gloria J. Baciewicz MD Strong Recovery

Medications used in Treatment of Alcohol and Drug Use Disorders What are the medications that are sometimes used in treatment? How does treatment help with the lifelong management of substance use disorder?

Medications for addiction treatment FDA approved meds exist for: Alcohol Opioids Nicotine No approved meds yet for: Cocaine Cannabis Methamphetamine

Meds Approved for Treatment of Alcohol Use Disorder Disulfiram (Antabuse) 1950 Naltrexone (ReVia) 1994 Acamprosate (Campral) 2004 Naltrexone monthly injection (Vivitrol) 2006

Disulfiram (Antabuse) Disulfiram-alcohol reaction Blocks acetaldehyde dehydrogenase Acetaldehyde builds up 250 mg per day Check LFT’s at baseline and 1 month after

Naltrexone (ReVia) Opioid antagonist: Affects endogenous opioids released by alcohol consumption, decreases alcohol craving and use Check LFT’s at baseline and 1 month after Main side effect = nausea Recent pharmacogenetic studies: NTX more effective in persons with G polymorphism of the gene OPRM1 (Anton R et al, Arch Gen Psych 2008)

Acamprosate (Campral) Blocks glutaminergic NMDA receptors & activates GABA type A receptors Decreases alcohol craving and use 666 mg tid No routine lab testing needed, few side effects Recent pharmacogenetic studies: more effective in patients with the common allele of the genetic variant rs2058878 located in the GRIN2B gene

Injectable Naltrexone (Vivitrol) IM Monthly 380 mg Expensive--about $700 per month Extra paperwork (faxes to the company) NYS Medicaid now supports this med

Summary of meds for alcohol dependence Naltrexone & acamprosate both have a place in treatment. Both have only moderate effects but are important clinical tools Disulfiram (Antabuse) still has some limited use Monthly Injectable naltrexone is increasingly being used

Drugs Approved for Treatment of Opioid Use Disorder Replacement therapies: Methadone Buprenorphine/naloxone (Suboxone) Partial agonist at mu receptor Problems with ORT : stigma, availability Antagonist therapies: Naltrexone: oral or monthly injection

THE MEANING OF SUCCESS in Methadone Maintenance SUCCESS = TREATMENT RETENTION Treatment retention produces: Reduced illicit drug use Reduced criminal activity Increased employment Improved general health status Lower rates of HIV/AIDS

Juice Bar Adequate dosage Additional psychosocial services What Produces Better Treatment Retention? Adequate dosage Caplehorn, J R. Bell, J. Kleinbaum, D G. Gebski, V J. Methadone dose and heroin use during maintenance treatment.Addiction. 88(1):119-24, 1993 Jan. Additional psychosocial services Mc Lellan AT, Arndt IO, Metzger DS, Woody GE, O' Brien CP. The effects of psychosocial services in substance abuse treatment. JAMA 1993;269(15):1953-9. Juice Bar

Buprenorphine Partial agonist Subutex, Suboxone Less respiratory depression Abusable but much less dangerous than other opioids

Opioid Overdose Reversal: Naloxone (Narcan) Intranasal Kits 5:30-6:30 pm First Tuesday of the Month Strong Recovery 275-3161 RSVP to: michele_herrmann@urmc.rochester.edu

Drugs for Nicotine Use Disorder Nicotine Replacement Therapy: Gum, patches, nasal spray, inhalers Bupropion (Wellbutrin, Zyban) Varenicline (Chantix) Partial agonist at nicotine receptor

Components of Comprehensive Drug Addiction Treatment A variety of scientifically-based approaches to drug addiction treatment exist. Drug addiction treatment can include behavioral therapy (e.g., counseling, cognitive therapy, or psychotherapy), medications, or their combination. Case management and referral to other medical, psychological, and social services are crucial components of treatment for many people as well. The best programs provide a combination of therapies and other services to meet the needs of the individual patient, which are shaped by such issues as age, race, culture, sexual orientation, gender, pregnancy, parenting, housing, and employment, as well as physical and sexual abuse. Several of the key principles underlying this approach to treatment follow. www.drugabuse.gov

Does treatment work? 30-50% abstinent after first year Complete abstinence not always achievable What’s an effective outcome? Reduction of use Improvement in health or social functioning Reduced threats to public health & safety

CalData study 1994 $1 Treatment $7 saved in other areas

How Does Treatment Work? Prolonged alcohol and drug use changes the brain – “neuroplasticity” Addiction “hijacks” the pleasure centers of the brain Addiction treatment programs and meds help “retrain the brain” Old pathways remain and can be triggered