Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination
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This brief overview of pharmacotherapies for alcohol and drug dependence will address three major issues: (1) FDA approved pharmacotherapies; (2) new pharmacotherapies under development; and (3) recommendations for appropriate use of existing and developing pharmacotherapies, particularly for patients in the criminal justice system. Four medications are now specifically approved by the FDA for use with substance dependent patients: methadone, LAAM (levo-alpha- acetyl-methadol), naltrexone, and disulfiram. Methadone, LAAM, and naltrexone are used for opioid dependence, while disulfiram is for alcohol dependence.1
All of these are medical treatments that might be provided in residential as well as outpatient programs. A newly developed agent for opioid dependence is buprenorphine. A new form of naltrexone is being developed for injection use so that it would need to be given every several weeks rather than several times per week. Naltrexone is also showing promise for reducing alcohol dependence. No pharmacotherapies are specifically approved for cocaine dependence, but a number of antidepressant medications are showing promise as treatments, and an active research effort is developing a cocaine blocker.
While specific guidelines apply to each of these medications, a critical component with any maintenance medication is concurrent psychosocial rehabilitation with appropriate monitoring of medication compliance and any continued illicit drug or alcohol abuse. Biochemical monitoring of illicit drug use through urine testing and of alcohol use through breathalyzer is an essential component of any pharmacotherapy program. Simply handing out these medications by monthly prescriptions or even by daily dispensing without these ancillary treatment components has been repeatedly demonstrated to fail in reducing alcohol and illicit drug abuse. No "magic bullets" exist for substance dependence, and these medications require a comprehensive treatment context.
In understanding the role of pharmacotherapies for substance dependence, it is important to distinguish between medications for acute detoxification and those for maintenance treatment. Acute detoxification can be medically serious and associated with life threatening complications that may require inpatient treatment, but maintenance treatments are designed for outpatients with the aim of preventing relapse to drug dependence. Many important pharmacological advances have been made in the acute detoxification of alcoholics and of opioid addicts. New medications such as carbamazepine for alcoholics have increased the safety and decreased the discomfort of detoxification. Other detoxification medications such as clonidine for opioid dependence have significantly reduced the duration of the detoxification from three weeks to as little as three days, and made these detoxifications more readily accessible to the general medical practitioner.
Maintenance treatments generally have no role in inpatient or longer term residential treatment except in special cases such as methadone maintenance of pregnant heroin addicts. Because opiate detoxification in these patients may lead to spontaneous abortion, methadone maintenance assures greater medical safety for both the mother and the fetus. The risks from opiate withdrawal in the newborn baby of methadone treated women are minimal, and many newborns will not experience significant withdrawal symptoms. Those who have withdrawal can be well treated with existing medications, and methadone has no deleterious effects on fetal growth or development.
Methadone maintenance is an important pharmacotherapy for heroin dependent patients. When used in an adequate dose of over 65 mg. daily and for a duration of at least two years in the context of a psychosocial rehabilitation program, methadone is clearly our most effective therapy for heroin addicts. Using once daily dosing, methadone relieves opiate withdrawal symptoms and, by a mechanism called cross tolerance, prevents heroin addicts from getting high from illicit heroin. Within methadone programs there have been problems with polydrug abuse, particularly cocaine abuse and alcohol abuse, as well as with potential misuse of methadone when take home bottles are given. In order to address this problem of misuse, LAAM was developed to enable patients to come in three times a week without needing to give them take home medication. For the problem of polydrug abuse, several new treatments have been developed. For example, disulfiram, an alcohol blocker, can be helpful when used in conjunction with methadone for alcoholic opiate addicts.
Methadone's role in preventing the spread of AIDS among intravenous drug users can not be underestimated. Areas having high incidence of injection drug use, the most common route of administration for heroin addicts, need to encourage methadone maintenance programs. The cost for medically treating an individual with AIDS is estimated at $100,000. Methadone maintenance costs approximately $6.00 per day, or $2,190.00 per year. Cost benefits alone are substantial; reduction in the transmission of the AIDS virus is equally impressive. In one recent study, the rates of new AIDS infections were four times higher in those heroin addicts on the street compared to similar former addicts who received treatment in methadone maintenance. It is estimated that $75,000 is saved in lifetime medical costs for each AOD-abuser diverted out of the disease pool through treatment.
Overall, methadone programs have been extremely effective at improving employment and reducing crime as well as reducing heroin abuse and AIDS transmission. It should be noted that some individuals may always require some dosage of methadone. However, the cost benefits far outweigh the necessity of long term methadone maintenance. Studies that analyzed cost benefits of methadone maintenance for opiate abusers have found a benefit/cost ratio of $4.4 to every dollar expended for methadone maintenance. The estimated ratio of benefits from reduced crime to costs of treatment was 1.7 to 1 for men over a two year period. The Treatment Outcome Prospective Study (TOPS) conducted in the late 1970s and early 1980s showed that the benefits justified the costs of methadone maintenance by:
The investment in public treatment is recovered substantially during the period when the heroin users are in treatment.
The other major medication available for heroin dependence is naltrexone, a blocker of opiates. Two important problems with naltrexone have been that heroin addicts must be detoxified from opiates before naltrexone can be started, and it requires continued patient compliance after detoxification. Detoxification has been greatly improved using clonidine plus naltrexone, and it has been shortened from about two weeks to as little as three days. One setting in which patient compliance problems have been significantly reduced is the criminal justice population. With these patients, continued three times a week ingestion of naltrexone can be made a condition of probation or parole or made part of a work release program. If these patients miss taking the medication, they are promptly returned to prison. With this contingency, heroin addicts do extremely well at remaining opiate free since naltrexone completely blocks the effect of heroin. An additional development has been an injectable form of naltrexone, which can be given as infrequently as once a month, rather than needing three times per week oral dosing.
Another available medication is disulfiram (antabuse) for alcoholism. This medication makes people sick if they use alcohol while taking it. Because patients have to take disulfiram every day, compliance with this aversive medication is its major limitation. If they take disulfiram regularly, patients are unlikely to abuse alcohol because they will get sick. Disulfiram has been used particularly effectively with alcoholic opiate addicts who are maintained on methadone because they can take both the methadone and disulfiram together, and methadone compliance is very good. In other settings, observed daily ingestion of disulfiram can occur at places of employment or through treatment programs tied to probation, parole, or work release.
Cocaine and stimulant abuse are major problems for which effective pharmacotherapies have yet to be developed. Several studies have demonstrated that antidepressant medications and some medications used for treating Parkinson's disease may also be helpful in reducing cocaine dependence. These medications are neither substitution agents such as methadone nor blocking agents such as naltrexone, but reducing craving for cocaine thereby reduces a patient's cocaine abuse. Current research is developing a blocking agent for cocaine similar to naltrexone in order to reduce cocaine's reinforcing properties. However, the mainstay of treatment for cocaine abuse remains psychotherapeutic treatments in conjunction with regular urine monitoring for cocaine.
In summary, medications can have a significant role in the treatment of substance abusers, particularly opioid addicts and alcoholics. The most widely used medication for opioid addicts is methadone; it has excellent treatment retention and substantially reduces illicit heroin use. In addition, psychosocial rehabilitation with these methadone patients can reduce crime, increase employment, improve psychological functioning, and stabilize health, particularly in patients infected with the AIDS virus. A blocker treatment, naltrexone, is also available for heroin addicts, but there has been a significant issue with compliance in the general heroin addict population. However, naltrexone can have a substantial role in work release or other criminal justice programs where compliance can be regularly monitored and enforced. This need for monitoring also may be reduced by depot forms of naltrexone, where once monthly injections will be sufficient for complete blockade. Finally, disulfiram can be very helpful in alcoholics, although monitoring compliance is a key issue, since daily ingestion is needed. With all substance abusers, polydrug abuse of cocaine in addition to alcohol or heroin remains a significant problem. While no blocking agents have yet been developed for cocaine, progress has been made in using antidepressants and other medications to reduce cocaine craving and thereby reduce cocaine abuse in motivated subjects.
It is vital to use all avenues of treatment in providing assistance to substance abusers. This includes those that are not traditionally approved of by the public and/or criminal justice system. Methadone maintenance, naltrexone, and disulfiram do assist some substance abusers in developing drug-free existences. Reducing drug use through pharmacological therapies diminishes the spread of infectious diseases, including AIDS and tuberculosis; reduces the level of criminal activity for those receiving pharmacological therapy; improves the rate of employment for individuals on pharmacological therapy, making them tax-paying, contributors to society; and reduces the intake of illegal drugs, thereby impacting the demand for substances of abuse. Pharmacotherapeutic interventions have their special niche for use with substance abusers; more importantly, they have application and use with the appropriate substance abusers involved with the justice system.
1. LAAM was approved by the FDA for use with opioid-dependent patients in July 1993 and is expected to be available in most States by the end of 1994.
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