During the early part of recovery from alcoholism or addiction the patient may experience extreme cravings which can lead to recurrent drug or alcohol abuse. A variety of medications exist which, when used appropriately in early recovery, can decrease the amount of craving that an addict will experience. The purpose of this article is to acquaint the reader with the various types of medications and their uses during early recovery. This article serves only as a brief introduction and is not an exhaustive discussion of the various medications, their side effects, or their other uses in clinical practice.
In keeping with a “first things first” approach, it will be necessary to discuss the limits of medication in the treatment of addictive disorders. Typically, addicts and alcoholics enter treatment with a philosophy of “better living through chemistry”. Unfortunately, modern medicine has done a lot to foster this maladaptive approach. It seems that we in the medical profession are always looking for that magic bullet, usually in the form of a medication or technical procedure, which will result in instant healing and cure of our patients. Clearly, there is some merit in this approach as seen in the numerous advances that have been made in the science and technology of medicine. However, like any other model, it has its limitations and these must be respected especially in the setting of the disease of addiction. The most important point to get across to the reader is that addiction is multifactorial; it encompasses biological, psychological, social, emotional, familial, and spiritual aspects of a patient’s life. The use of medication, while important for treating some aspects of the disease, is by no means a panacea. In order for this disease to be effectively treated it must be approached on all these different levels.
In early recovery some medications have been demonstrated to have some salutary effects with respect to the control of craving. In the setting of alcoholism, there are two medications for the control of craving and one medication which acts as negative reinforcement with respect to the consumption of alcohol. The medicines which are effective for craving are naltrexone and acamprosate. Naltrexone is an opiate antagonist within the central nervous system which was observed to decrease alcohol consumption. It comes in oral and injectable formulations. The injectable formulation, while very expensive, is the preferred treatment because it results in greater compliance (i.e. patients are able to take it reliably) than the oral formulation. Acamprosate targets the brains glutamate system and it is an oral formulation taken three times daily. Disulfiram, also known as Antabuse, is the oldest medication- based treatment for alcoholism and it acts as a negative reinforcement to drinking. If a patient taking Antabuse begins to drink alcohol they will become extremely ill to the point of requiring a visit to the emergency room. The rates of compliance with Antabuse are low, but it is frequently used in early sobriety when it is given by a concerned relative or by medical personnel who can supervise its consumption.
In the setting of opiate addiction, the two drugs which are effective for the control of craving are methadone and Suboxone. Both of these medicines can be used during detoxification and can also be used for induction of opioid maintenance. Methadone is a narcotic with a long half-life which has a lower abuse potential than other shorter acting narcotics. The advantage of methadone is that it is cheaper than Suboxone, but its principal disadvantage is that it requires attendance at a methadone clinic on a frequent basis. Suboxone does not carry the same stigma that methadone carries and it can be prescribed in the outpatient setting by any physician with a special license to do so. Another medication which can be helpful in the setting of opiate addiction is clonidine. This is actually a blood pressure medication which has been found to ease the symptoms associated with detoxification.
The medications which have been effective in decreasing craving in the setting of stimulant or cocaine abuse have included the following: Antabuse, Provigil (a non-amphetamine stimulant), propranolol, baclofen, and Topamax. Drug manufacturers are also pursuing the development of a cocaine vaccine which would produce cocaine-specific antibodies that would bind to cocaine in the circulation and prevent it from crossing the blood brain barrier.
For those patients interested in smoking cessation, a variety of medications can help with the control of craving including: nicotine supplements in the form of gum or patches, bupropion (an atypical antidepressant), and Chantix. Recently however, Chantix has been found to have unfavorable side effects including: depression, anxiety, suicidal thoughts or behaviors, and even psychotic symptoms. The FDA has recently issued a blackbox warning for Chantix highlighting the aforementioned adverse effects. In any event, the medications used to decrease craving in the setting of nicotine addiction are only effective in terms of smoking cessation if they are combined with a behavioral plan targeted at abstinence.