Why are Treatment Centers Afraid of Anti-Craving Medications?

Using What Works

Why do so many drug treatment centers continue to shun science by ignoring medications that ease the burden of withdrawal for many addicts? That’s the question posed in an article by Alison Knopf in the May-June issue of Addiction Professional, titled “The Medication Holdouts.”

“Nowhere else in medicine,” Knopf writes, “are the people who treat a condition so suspicious of the very medications designed to help the condition in which they specialize.”

Acamprosate, a drug used to treat alcoholism, is a good case in point. A dozen European studies examining thousands of alcohol test subjects found that the drug increased the number of days that most subjects were able to remain abstinent. But when a German drug maker decided to market the drug in the U.S., fierce advocates for drug-free addiction therapy came out in force, even though the drug was ultimately approved for use.

Disulfiram, naltrexone, acamprosate, methadone, buprenorphine—the evidence for all of them is solid. Knopf cites the case of buprenorphine:

“‘There are scores of peer-reviewed journal articles that evaluate the success of buprenorphine,’ says Nicholas Reuter, MPH, senior public health adviser in the Division of Pharmacologic Therapies at the federal Center for Substance Abuse Treatment (CSAT). ‘It's well established that the data and the evidence are there. Not treating patients with a medication consigns most of them to relapse, adds Reuter. While some opioid-addicted patients, as many as 20 percent, do respond to abstinence-based therapy, ‘That still leaves us with the 80 percent who don't,’ he says.”

Dr. Charles O'Brien, one the nation’s most respected addiction professionals and a Professor of Psychiatry at the University of Pennsylvania, is incensed that anti-craving medications are not more widely used. “It's unethical not to use medications,” he says. “This is a subject that I feel very strongly about.” O’Brien told Addiction Professional he no longer cares who he offends on the subject. “If you're discouraging people from taking medications, you are behaving in an unethical way; you are depriving your patients of a way to turn themselves around. Just because you don't like it doesn't mean you have to keep your patients away from it.”

And at the Association for Addiction Professionals, “the prevailing philosophy is pro-medication,” Knopf writes. Misti Storie, education and training consultant for the group, told Knopf that the “disconnect” at treatment centers is due to a “lack of education about the connection between biology and addiction.” Counselors working in centers that do not allow anti-craving medications are in a tough spot, Storie acknowledged.

It is continually astonishing that treatment centers--where the primary goal is supposed to be the prevention of relapse, even though the success rate remains abysmal--would spurn medications that often help to accomplish precisely that goal. Relapse rates hover around 80%, by an amalgam of estimates, so it’s not like rehabs are wildly successful at what they do. What’s really behind the resistance?

What stands between many addicts and the new forms of treatment is “pharmacological Calvinism.” I would love to claim this term as my own, but it was coined by Cornell University researcher Gerald Klerman. Pharmacological Calvinism may be defined as the belief that treating any psychological symptoms with a pill is tantamount to ethical surrender, or, at the very least, a serious failure of will. As Peter Kramer quoted Klerman in Listening to Prozac: If a drug makes you feel better, then by definition “somehow it is morally wrong and the user is likely to suffer retribution with either dependence, liver damage, or chromosomal change, or some other form of medical-theological damnation.”

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A New/Old Treatment for Opiate Addiction

 

Gov makes naltrexone legit for heroin.

Last week, the government officially sanctioned the use of naltrexone, trade name Vivitrol, for use in the treatment of heroin addiction. Approved years ago by the FDA for use in the treatment of alcoholism, naltrexone is a long-acting opiate receptor antagonist that has been widely used for heroin detoxification, withdrawal, and maintenance for some time. In that light, the official approval was a bit of an anticlimax, and of less scientific interest than naltrexone’s earlier approval for alcohol dependence. 

While naltrexone has yet to become the huge treatment breakthrough for alcoholism that addiction researchers hoped for it, naltrexone did, in the end, prove to be the first anti-craving medication widely available for alcoholics. Using an opiate antagonist as an aid to the prevention of alcoholic relapse would have been unthinkable without the underpinnings of a neurophysiological model of addiction. Various investigators have also speculated that naltrexone, the drug used as an adjunct of heroin withdrawal therapy, may find use against symptoms of marijuana withdrawal in people prone to marijuana dependence

Naltrexone has something of a mixed reputation, however, in part due to its use in the highly controversial practice of “rapid detox.” Naltrexone, like methadone and buprenorphine, blocks the heroin high in a relatively neutral manner. It does so by knocking the opiate molecule off its receptors and replacing it with “dead weight,” so to speak. Naltrexone would seem to be the perfect drug for heroin addicts—but it is not. It does little to reduce cravings. Like acamprosate for alcohol, another blocking approach, its record of accomplishment is mixed, and the dropout rate is high. There is not even a mild drug-like effect to provide cross-tolerance and dampen the effects of withdrawal, as with methadone. Recently, naltrexone for heroin addiction has been offered as a form of rapid detoxification. The addict is anesthetized and placed on a respirator, then injected with naltrexone. The result: complete detoxification in a matter of hours, as the naltrexone molecules knock the opium molecules off their receptors. It can be lethal if not carefully controlled and supervised. The problem, as always, is that the detoxified addict is just as vulnerable to heroin addiction as before. Rapid detox does nothing to combat subsequent cravings, and relapse is frequent.

 Naltrexone combined with buprenorphine is marketed as Subutex, and represents another treatment modality for opiate addiction.  In addition, a University of Minnesota study of kleptomania—the compulsion to steal—showed that naltrexone drastically reduced stealing among a group of 25 shoplifters.

Naltrexone will be offered as a monthly injection, an approach that has not been widely tested on opiate addicts, but is potentially an advantage over frequent visits to methadone clinics or daily ingestion of other treatment drugs. Unfortunately, naltrexone is a potential problem for people with liver disease or hepatitis.  At high doses, naltrexone has been implicated in liver damage. More common adverse effects include dizziness, lethargy, and headache.

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Anti-Craving Drug Eases Pain of Fibromyalgia

Naltrexone being studied for immune-related disorders.

A drug frequently used to treat heroin and alcohol addiction also eased the pain of women suffering the symptoms of fibromyalgia, according to a Stanford study published in the April 17 journal of Pain Medicine.

Fibromyalgia remains a controversial diagnosis. As reported by Coco Ballantyine in Scientific American online, it is a “mysterious ailment whose symptoms include chronic widespread muscle pain, fatigue, sleep problems, anxiety and depression, often appears between the ages of 34 and 53 and is more common in women.”

Jarred Younger and Sean Mackey of the Stanford School of Medicine’s pain management division reported that pain and fatigue ratings for the women dropped by 30% over the 14 weeks of the study. “Patients’ reactions were really quite profound,” said Mackey. “Some people went back to work really improving their quality of life.”

Tara Campbell, one of the patients involved in the study, told the Stanford News Service that she was feeling “really, really good.” She said “my improvement was about 40 percent in the study. When you’re not capable of doing much of anything, that’s a lot... I’m much more back to normal.”

Younger said he became interested in studying naltrexone after he began questioning patients who claimed to be suffering from the disorder. “I was asking patients, ‘Does anything work for you?’ A lot of people in support groups were saying, ‘Yeah, I tried naltrexone and it works for me.’”

Naltrexone is currently used as a treatment for heroin addiction and for alcoholism. (See my post, "Drugs for Alcoholism.") Naltrexone works by locking into central nervous system receptors normally occupied by opiates or by the body’s own endorphins. Researchers like Younger, however, believe that naltrexone also dampens the activity of immune cells known as microglia that are involved in inflammatory responses.

It is not uncommon for scientists to investigate the additional effects of drugs in common use. “From a regulatory point of view,” said Canadian addiction researcher Edward Sellers in my book, The Chemical Carousel, “companies don’t try to develop [new drugs] for forty-three different things. But these drugs still carry with them many other pharmacologic actions. The history of virtually every drug that comes to market is that all these other secondary applications start to manifest themselves.”

Graphics Credit: http://www.aocbv.com/fibromyalgia.html