A Guide to Medications in Recovery

A discussion of the use of pharmaceuticals in drug treatment, known as medication-assisted treatment, touches on every aspect of the recovery process. At the outset, it is critical to dispel any misconceptions about the use of prescription drugs to treat drug abuse. There is no wide-sweeping “pill fix” to treat drug abuse; use of medications is limited and depends on the type of drug abused and the treatment policy of the rehab facility that is providing the care.

It is important to note that medication is never a substitute for a comprehensive treatment plan. As substance abusers, their loved ones, and anyone working in the field of addiction treatment understands, addiction is a highly complex phenomenon that cuts across physical, mental, and social dimensions. For this reason, a multidisciplinary treatment approach is required to treat the different, but interactive, aspects of this illness. The use of drug abuse treatment medications, where applicable, can be an effective part of a multidisciplinary approach.

Secondly, medications can be introduced during different times and phases of treatment such as a:

• Vaccine: Researchers are currently exploring this prevention measure in the area of cocaine abuse.
• Overdose treatment: Rapidly acting antidotes are a critical part of emergency medical services.
• Detox aid: This is used to help manage the uncomfortable or painful side effects of withdrawal.
• Primary care treatment: In some instances, such as with methadone treatment for opioid abuse, the use of medications can be an effective defense against relapse and supportive for long-term recovery.
• Aftercare aid: Short-term or long-term use of medications, such as Suboxone, may be prescribed for some recovering abusers and may be instrumental in preventing a relapse.

When it comes to the use of medications in drug treatment, there is an important distinction to be made between drugs that are specifically designed to treat the addicted brain and body (like drug antagonists/blockers) and those that have purely palliative purposes, like muscle relaxers. As withdrawal during detox can include painful side effects, some rehab programs will provide prescription and over-the-counter medications to make the process more comfortable. The use of palliatives like muscle relaxers and non-prescription pain relievers are low-impact and not the subject of this article, which focuses on medications used to treat addiction.

As the Substance Abuse and Mental Health Services Administration points out, certain medications are useful in the treatment of alcohol and opioid dependence.^[1] The U.S. Food and Drug Administration (FDA) has approved the following medications for use in drug recovery programs:

Pharmaceuticals used to treat alcohol abuse:

• Naltrexone (branded names include Vivitrol and ReVia)
• Acamprosate Calcium (Campral)
• Disulfiram (Antabuse)

Pharmaceuticals used to treat opioid abuse:

• Methadone
• Naltrexone
• Buprenorphine (branded names include Suboxone and Subutex)

The National Alliance for Medication Assisted Recovery (NAMA-R) is an organization dedicated to advocating for recovering substance abusers, addiction treatment providers, and other concerned persons who believe in using opioid medications to assist in opioid recovery (such as methadone). The group works to eliminate bias in this form of treatment, provide recovering persons with an empowered platform to voice their insights and feelings about medication-assisted treatment, and to promote access to this treatment option. The group maintains an online library devoted to topics in the pharmacology and opioid treatment realm.

Again, not all drugs of abuse are treatable with medications. For instance, the FDA has not approved a medication to treat cocaine addiction.^[3] This is not for lack of interest or necessity. As the 2013 National Survey on Drug Use and Health found, 1.5 million Americans aged 12 or older were current cocaine users (0.6 percent of the total population).^[4]

The National Institute on Drug Abuse (NIDA) is diligently working to develop a pharmaceutical-based treatment for cocaine abuse. In some instances, a drug marketed for one purpose can be used “off-label” for a different purpose. In some clinical trials, Disulfiram, which is used to treat alcohol abuse, has been shown to be effective in cocaine abuse recovery treatment. Currently, researchers are working to test medications that act on the neurotransmitters in the brain involved in cocaine abuse (such as glutamate, gamma-aminobutyric acid, and dopamine D3 receptors).

Addiction treatment with medication can only go as far as the advances that have been made in addiction science. As discussed, medication-assisted treatment presently focuses on alcohol and opioid abuse. However, substance abusers of other drugs are by no means crippled in their recovery efforts simply because there are no FDA-approved medications for the treatment of their particular drug of abuse (such as cocaine). In the future, as the use of medications expands to treat different drugs of abuse, the key will be to compare recovery results before and after the introduction of such medications.

Currently, substance abusers in recovery from drugs other than alcohol and opioids can benefit from traditionally structured treatment programs that include:

• Detox services: Almost all recovery programs begin by eliminating the drug(s) of abuse from the substance abuser’s system.
• Maintenance treatment: Post-detox, primary care treatment helps the recovering substance abuser to address the reasons behind the substance abuse.
• Behavioral therapy: This component addresses the mental thoughts, attitudes, perceptions, and resulting behaviors that underlie drug addiction.
• Family therapy: Loved ones play an instrumental role in leading substance abusers into treatment, and they can further assist the process by participating in group sessions and educational workshops and seminars.
• Complementary therapy: Forms include yoga, massage, acupuncture, and animal-assisted therapy (depending on program availability), and these therapies can supplement a traditional treatment plan.
• An aftercare plan: This is an essential element of treatment after graduation from an inpatient or intensive outpatient program and may include residence in a sober living home, attending individual counseling, joining a recovery group, working with a sober sponsor, and meeting periodically with an addiction treatment counselor.

Methadone

As the Centers for Disease Control and Prevention discusses, although methadone is a medication that has been used to treat opiate dependence (such as dependence on heroin) since the 1960s, this form of treatment remains the subject of debate.^[5] The abuse of prescription pain reliever opioids (such as OxyContin and hydrocodone) has reached an epidemic level in America, which has only fanned the flames of the debate over whether it is advisable to use opioids to treat opioid abuse.

Some addiction professionals believe that a truly drug-free state is necessary to achieve sobriety. Opponents of methadone maintenance treatment urge that methadone programs attract crime and drug dealing to communities.^[6] A grave concern is that methadone users divert this drug to non-prescribed users for money or other benefits. In short, for some, methadone is a troublesome antidote that may just not be worth the trouble.

Fast Facts on Methadone

• This synthetic narcotic was first legally distributed in the US in 1947.
• Methadone comes in the form of a tablet, oral solution, and injectable fluid.
• Withdrawal symptoms from methadone include nausea, muscle tremors, diarrhea, abdominal cramps, and vomiting.
• Street names include fizzies, amidone, wafer, and chocolate chip cookies (when MDMA is added).

Source: National Drug Intelligence Center

Methadone maintenance treatment is a firmly entrenched recovery practice, in part because methadone has been proven to provide the following benefits:

• Prevents opiates from inducing a sedative or euphoric effect, and thus reduces the risk of opiate abuse
• Stems cravings for opiates and thereby lessens the risk of relapse
• At properly supervised dosage levels, methadone does not cause intoxication
• Reduces drug usage, thereby lessening the risk of overdose and contracting infectious diseases
• Can reduce the symptoms associated with opiate withdrawal

Whether a person falls on the advocate or opponent side of the methadone maintenance treatment debate, no one can deny that while this narcotic is susceptible to abuse, it has proven to be effective in the opiate recovery process. The key to successful methadone use is to strictly observe the supervising doctor’s or clinic’s treatment plan.

Methadone use is associated with common side effects including weight gain, constipation, nausea, headache, and dry mouth but it is considered a safe drug overall. Regarding long-term use of methadone, it is important for recovering users to understand that some recovery groups and sober living homes have a zero drug use tolerance policy, which even includes medication-assisted treatment, such as methadone. Ultimately, it will be the decision of the recovering opiate abuser to weigh the pros and cons of methadone use.

Naltrexone

As the Substance Abuse and Mental Health Services Administration points out, opioid addiction is a chronic disease, but it is treatable.^[8] Naltrexone is an opioid blocker that can assist recovering opioid abusers in maintaining abstinence and avoiding relapse. Naltrexone can be used as part of a primary care and/or aftercare program.

Using naltrexone blocks the effects of opioids on the reward system of the brain. When the prescribed dosage is taken, naltrexone does not induce a “high” and therefore is not susceptible to abuse. Further, naltrexone has proven effective in reducing drug cravings. As naltrexone may effectively block the effects of opioids, curb or stop cravings, and does not usually produce psychoactive effects, the benefits of use generally outweigh the risks.Naltrexone is available in pill form (as a generic, or by the brand names ReVia and Depade). An extended-release version is also available in an injectable form (brand name Vivitrol). When prescribed as an injection, qualified medical personnel administer the dose to the buttocks, usually on a monthly basis. Convenience is a contributing factor to recovery success, and the injectable option may be a good choice for those who have work or other time demands. Depending on the specific needs of the recovering substance abuser, naltrexone may be prescribed for days, months, or years.An additional benefit of naltrexone is that it is not addiction-forming; however, naltrexone users face a different risk that is quite serious. As naltrexone blocks the effects of opioids, some users who relapse make the mistake of consuming a large quantity opioids to try to overcome this effect. Overdose may result under these circumstances, and it can be fatal.

Buprenorphine

When used in compliance with a medically supervised treatment program, buprenorphine is generally safe and effective. Similar to naltrexone, buprenorphine is proven to reduce opioid cravings and can help to manage withdrawal symptoms. Buprenorphine comes in pill form, to be dissolved under the tongue (not chewed or swallowed). There are two branded forms, Suboxone and Subutex. Whereas Suboxone is a combination of buprenorphine and the drug naloxone, Subutex is composed solely of buprenorphine.

Buprenorphine Regulation

Buprenorphine was the first drug the U.S. Food and Drug Administration approved for use in doctors’ offices for treatment of opioid abuse. Per the U.S. Drug and Enforcement Agency, buprenorphine is a Schedule III drug, which means it has a propensity for abuse but serves a medically recognized and lawful treatment purpose. Although buprenorphine use can lead to dependence and abuse, the Schedule III classification attests that this drug is not as addictive as Schedule II drugs.

Source: SAMHSA

Buprenorphine can be prescribed for opioid recovery treatment for as long as necessary to help prevent relapse. Some recovering substance abusers take this prescription medication for days, months, or even years. Buprenorphine has several benefits, including:

• Low overdose risk
• Long-acting so over time a user can go from daily use to taking it every other day
• With a prescription, dosing can occur at home
• Tapering off is a safe way to ultimately discontinue use

Buprenorphine is dependence forming. It is important to note that physical dependence on a drug does not necessarily lead to addiction, although addiction can result in some instances. Addiction to prescribed medications, such as buprenorphine, is less likely to occur in users who strictly follow their treatment plan. Once physical dependence on buprenorphine has developed, users are best advised not to abruptly stop taking this drug. Being weaned off buprenorphine, under medical supervision, is the safest practice.

12-Step Programs and Medication Assisted Treatment

Despite the benefits of medication-assisted treatment, the practice faces some backlash. As discussed in Asamagazine, a publication dedicated to addiction medicine, there is a strong current of opinion that using opioids to treat opioid abuse is really just substituting one drug for another. As Asamagazine points out, this argument may arise in the context of 12-step group meetings. While peer support has proven helpful for many recovering substance abusers (even indispensable, in many cases), one danger is that a group’s opinion may be believed to have a sound factual basis when in fact it does not.

In contemplation of the propensity for group opinion to overtake reason, Alcoholics Anonymous (which provides the original model for 12-step meetings) specifically advises members not to give advice to one another. AA encourages its members to follow doctors’ order, which by extension may include being on a medication-assisted treatment plan.^[13] It is critical for 12-step members who are in a medication-assisted treatment program to be aware that there is support for the practice at the greater organizational level, which may not be reflected in the sentiments of individual members. A difference of opinion among 12-step group members regarding medication-assisted treatment should never result in discontinuing meeting attendance, although it is always advisable for recovering substance abusers to join the most suitable group available.

There is no dispute that the key to long-term recovery is achieving and maintaining abstinence. For some recovering substance abusers, particularly those who abused opioids, the need for “abstinence” justifies the consumption of opioid treatment medications. For instance, substance abusers with co-occurring mental health disorders are particularly good candidates for medication-assisted treatment, which may be essential to achieve and maintain long-term recovery. Although treatment medications are drugs, from a psychological standpoint, their use is not addiction-related when used for a medical purpose. A more realistic and working definition of “abstinence,” therefore, would not be based on the absence of drugs from the system, but on the absence of an abuse intention. Substance abuse cannot be treated with black-and-white thinking, but certain viewpoints may attempt to do just that.

Medication-assisted treatment is an important part of the recovery process for some substance abusers, and it must be adapted to work in conjunction with other methodologies, such as behavioral therapy. Any perception that using medication is tantamount to a weak link in the recovery process is most likely to be a matter of personal perception rather than scientific evidence. Recovery is always an exploratory process; when under the care of a supervising doctor and team of addiction specialists, treatment must always be responsive and flexible to meet the recovering person’s developing needs. Medication can healthfully contribute to the process, and if kept in appropriate balance with other aspects of treatment, it may improve the likelihood of a successful long-term recovery.