The National Survey on Drug Use and Health (NSDUH) reports that in 2014 one out of every 12 American adults suffered from addiction to drugs or alcohol or a combination of both. Drug dependence is typically a side effect of addiction. Mind-altering substances can interfere with normal brain function and, with repeated use, can also lead to drug dependence and changes to the structure and chemistry in the brain. In short, the brain adapts to the presence of these psychoactive substances.
Drugs such as opioids, for example, bind to opioid receptors in the brain, decreasing anxiety and blocking pain sensations while increasing levels of neurotransmitters that are involved in feelings of pleasure, motivation, movement, learning, and memory formation. With regular use of these drugs, the brain stops transmitting, and even producing, its natural chemical messengers at the same rates as it used to. Physical dependence sets in. When someone is dependent on a drug, they will often suffer from withdrawal symptoms and significant cravings when the drug processes out of the body. Some of these withdrawal symptoms can be dangerous and even potentially life-threatening.
For this reason, when a person is dependent on opioids, alcohol, or benzodiazepines, it is never recommended to stop taking the substance “cold turkey,” or suddenly. Often, a medical detox program is the optimal method to allow the drugs to safely process out of the brain and body. During medical detox, medications are commonly used to alleviate and minimize drug withdrawal symptoms. Pharmacological tools can also be beneficial beyond detox to keep withdrawal symptoms at bay and minimize cravings and episodes of relapse.
Medications often play a vital role in addiction treatment and recovery, and they may be dispensed and monitored through a medication management program. The American Society of Addiction Medicine (ASAM) publishes that medication management may serve to enhance treatment outcomes. Medications are generally only part of a comprehensive treatment plan that will also include therapies, counseling, and ongoing support. A medication management program can help to foster and enhance a sustained recovery.
When to Use a Medication Management Program
A medication management program may be appropriate in the following instances:
- In cases of opioid or alcohol dependence to help with detox and prevent relapse
- When medical or mental health issues are also present (co-occurring disorders)
- When poly-drug abuse is a factor
- To reduce injection drug abuse and minimize public health risks associated with this method of drug use
- For outpatient detox services
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Treatment Improvement Protocol (TIP) postulates that medications and medication management are often an important aspect of addiction treatment. When combined with therapies and a comprehensive treatment plan, they can be highly beneficial to long-term recovery. In order to decide if a person will benefit from medication management, first, a detailed assessment is done by trained professionals. Physical and mental health histories as well as substance abuse patterns and environmental aspects are explored. Medications may be necessary to help with symptoms of co-occurring disorders as well as for drug dependence, for instance.
Injection drug abuse is a highly risky pattern of drug use that can lead to numerous health risks, such as the contraction of an infectious disease like HIV/AIDS or hepatitis, as well as many social, behavioral, and public concerns. A medication management program may seek to limit this method of abuse instead of focusing on complete abstinence immediately. Drugs like heroin and prescription painkillers can induce intense cravings, and relapse rates for drug abuse and addiction are as high as 40-60 percent, the National Institute on Drug Abuse (NIDA) warns. A medication management program may be able to minimize relapse by helping to mitigate drug cravings.
Details of a Medication Management Program
ASAM reports that over 2.5 million people in the United States suffer from opioid addiction (as of 2015). Most medication management programs involve opioid drugs. Opioid drug medication management programs must be certified by SAMHSA and accredited by a SAMHSA-approved accrediting body. Facilities may be inpatient or outpatient and also provide counseling, therapy, and other treatment services as part of a medical management program. Medications are evaluated regularly and dispensed by trained providers.
There are three main medications that are approved to treat opioid dependence by the FDA (U.S. Food and Drug Administration): methadone, buprenorphine, and naltrexone. Each is used for a specific purpose and dispensed according to federal guidelines explained by SAMHSA.
Medications Used for Opioid Detox
Methadone (Dolophine, Methadose)
A long-acting opioid drug, methadone may be used during detox to replace shorter-acting opioids such as heroin. Longer-acting drugs can be dispensed less frequently and then tapered off slowly to avoid the more significant withdrawal symptoms and cravings. During a medication management program, methadone is dispensed once a day in tablet, diskette, or oral liquid concentrate form through federally regulated clinics. As an opioid agonist, it fills opioid receptors in the brain much like other opioids do. For this reason, it also carries a risk of abuse and dependence itself and must be prescribed under the watchful eye of highly trained providers.
Buprenorphine (Buprenex, Subutex)
Buprenorphine is a partial opioid agonist that does not fully activate opioid receptors, although it does to some extent. This means that the drug can minimize cravings and withdrawal symptoms without producing the euphoric “high” of other opioids. After a certain amount is ingested, buprenorphine stops having any effect, which deters its abuse.
Buprenorphine comes in many forms, from a sublingual film to a tablet and a patch for extended use. It is also usually dispensed daily, but can be also prescribed for individuals to take at home. Dosage may vary depending on the needs of the individual.
Buprenorphine is also often combined with the opioid agonist naloxone (Zubsolv, Suboxone, Bunavail). The antagonist component remains dormant unless the drug is altered and taken via injection. In this way, the naloxone works as a deterrent to abuse, as abusing it can induce painful withdrawal symptoms.
Naltrexone (ReVia, Depade)
Naltrexone is an antagonist drug that is typically given once a month via injection. As an antagonist drug, naltrexone is not taken until after a period of abstinence has been established. It serves to block opioid receptors from receiving any drugs, essentially curbing the desired effects of an opioid drug; therefore, it helps to reduce relapse and extend compliance and abstinence during recovery.
Other medications may be useful during detox and withdrawal to help with specific side effects. Pharmacological tools are also often needed to manage co-occurring medical or mental health disorders as well.
Medications Used for Alcohol Detox
Alcohol dependence may also be treated with a medication management program following detox. The following drugs may be used:
A deterrent medication that helps to minimize cravings, disulfiram induces unpleasant side effects like nausea, headache, and vertigo if a person drinks alcohol while taking it. It is dispensed in tablet form to be taken once a day at least 12 hours after the last drink of alcohol and generally after detox is completed. Disulfiram may be used during a medication management program to enhance sobriety and prevent relapse.
Also, an abstinence maintenance medication, acamprosate may be taken after close to a week of abstinence (i.e., after detox usually). It is taken in tablet form three times a day to manage cravings and prevent relapse. It does not relieve alcohol withdrawal symptoms, which is why it is typically administered after detox is completed.
Just as with opioid dependence, naltrexone serves to block the pleasant side effects that a person may feel while drinking alcohol, thus working as a deterrent for abuse and helping to prevent relapse and a return to problem drinking after detox.
Goals of Medications Management Programs
The long-term goal of a medication management program is to improve the quality of life of a person struggling with drug addiction and to help lead them into recovery, optimally eventually without the use of drugs. A medication management program may work to slowly reduce a person’s dosage of maintenance medications over time in order to wean them off medication completely. This is called a taper.
Each client is different, and the amount of time spent in a medication management program will depend on environmental, physical, and emotional factors, including support at home, presence of co-occurring disorders, and the severity of the drug dependence. An outpatient medication management program will generally require consistent check-ins and evaluations to ensure the dosage is effective and the individual is moving forward in recovery. Dosage will typically be adjusted slowly and in a controlled fashion. Counseling and behavioral therapy sessions are generally part of the program as well. A medication management program may follow, or be part of, a residential treatment program as well.
The long-term goal of a medication management program is to help an individual battling drug addiction to sustain recovery and lead a fulfilling and self-directed life.