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Chapter 8 of TAP 11: Treatment of Alcohol and Other Drug Abuse: Opportunities for Coordination

Chapter 8–Pharmacotherapies for Alcohol and Drug Dependence

by Thomas R. Kosten, M.D.

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.

Acute Detoxification Versus Maintenance Treatment

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 and LAAM Maintenance

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: