When I first entered treatment in 1982, I struggled with guilt and shame. As a psychiatrist, I was trained to see addiction as a symptom of something else, such as depression or a personality disorder. This was the understanding of the day in the scientific and psychiatric community. Today this community fully embraces the disease model. My professional rejection of the disease model fueled my personal belief that I was defective and even weak willed. I can remember the day I heard the Disease of Chemical Dependency lecture given by the pioneer in addiction medicine, Doug Talbott, MD. It felt as if a weight had been lifted off my shoulders. I finally understood why I did what I did. It did not free me of the responsibility for my recovery, but it helped me get past an often paralyzing self-condemnation.
“Hardware” Treatment Interventions
The disease model is reductionist; that is, it demonstrates how the brain influences behavior, thoughts, and feelings. This is an important part of the equation that allows us to use direct measures, like medication or even electrical stimulation, to influence brain mechanisms.
Direct measures target the hardwiring of the brain, analogous to the hard drive of a computer. The ability for thoughts, feelings, and behavior to feedback and influence the brain can be thought of as software programming. Although somewhat simplistic, these concepts can help conceptualize an approach to addiction recovery integrating mind, body, and spirit.
Various pharmacologic interventions that target brain function can be viewed as “hardware” interventions. They involve specific medications for the addiction (e.g., to target cravings or to block reward mechanisms) or medication strategies for common co-morbid conditions such as depression or anxiety disorders. Certain conditions, such as ADHD, chronic pain, sleep disorders, or anxiety, can be more difficult to treat because many of the medications used for these particular conditions have the potential to be addictive.
Specific Medications for Addiction and Co-morbid Issues
Medications can play a critical role in the management of addictive diseases. Anti-craving medications such as acamprosate and naltrexone have proven efficacy in positive treatment outcomes.
Acamprosate (Campral) is thought to modify the glutamate that can cause craving. This medication can also help with anxiety over time.
Naltrexone, which can temper craving and also block the reinforcement of alcohol and opiates, is particularly helpful for the addicted professional. For example, a healthcare professional (e.g., an anaesthesiologist) addicted to opiates may agree to take naltrexone so he or she can return to a work environment in which narcotics are accessible. Treatment with naltrexone can enhance the confidence of both the recovering addict and the workplace that agrees to reinstate or hire a newly recovering professional. An injectable form of naltrexone, Vivitrol, is now approved for alcohol and opiate dependence (there is recent discussion about efficacy in reducing stimulant intake as well) and can be administered monthly. To date, Vivitrol has been the most useful addiction-specific medication.
Naltrexone may work best for a subgroup of alcoholics who are “endorphin sensitive.” One-third of this subgroup could have a robust response to the medication, and some may even experience a mild reinforcement effect hypothesized to be from the naltrexone that facilitates hidden opiate receptors. For opiate addicts, naltrexone completely occupies the opiate receptor and will block any outside opiate effect. Research suggests it helps treat cravings as well, and outcomes are especially good for opiate dependence.
Vivitrol is injected monthly, so compliance during that month is not an issue. Vivitrol also creates a steady level in the blood, and much less of the drug has to be used. Other than injection site sensitivity in about 10% of patients, there are minimal side effects (e.g., nausea, headaches, and irritability), and if present, side effects usually last only a day or two after the first injection. Patients may need to be on Vivitrol for a few months or several months, depending on their individual needs.
Suboxone (buprenorphine plus naloxone) is a partial agonist. It occupies the opiate receptors in the brain’s reward center, partially blocking and partially activating them. This medication can produce some reinforcement initially, but that tends to diminish over time. It will block the effect of opiates like heroin or hydrocodone. There is some abuse potential, but Suboxone is generally safe if taken as prescribed. The naloxone is inactive unless the drug is injected (a way to abuse the medication), and the activation blocks the medication from its partial-agonist effect.
Suboxone is used to help patients detox from opiates and in some cases it is used for long-term treatment of opiate dependence. It can be useful for patients who have had repeated relapses or problems with opiate dependence associated with chronic pain. Suboxone can be an effective replacement for methadone in many cases. Some opiate addicts use Suboxone as a way to continue their opiate abuse—it allows them to detox themselves between opiate uses and be more comfortable when they can’t score their drug.
Other strategies include using Antabuse, which can produce negative effects if the user drinks alcohol while using it, and it has some similar reported effects with cocaine. Certain anticonvulsants like depakote or topiramate have reported benefits in reducing alcohol consumption.
Medication Treatments for Psychiatric and Medical Co-morbidities
Co-existing psychiatric illnesses such as depression, anxiety disorders, and personality disorders are common in addicted patients, including professionals. Diagnosis and aggressive treatment of these conditions are essential for positive outcomes. This holds true for medical co-morbidities as well, especially chronic pain conditions that frequently co-occur.
Depression commonly accompanies addiction. The challenge is to determine whether the depression is a consequence of the addiction, which often can occur. If the depression exited prior to the onset of the addiction, or remained there during periods of sustained abstinence and recovery, it may be separate from the addiction. Usually depression that is secondary to the addiction goes away after several days in recovery. If the depression hangs on, treatment with an antidepressant may be necessary, and poses no particular risk of abuse and may help even if the depression is secondary to the addiction. Mindfulness-based cognitive therapy for depression also is an approach for relapse prevention in substance abusers, and it may be helpful as an option concurrent with addiction treatment. In situations where it is unclear whether the depression is secondary to the addiction, we advise a drug holiday at some point to see if the antidepressant is still necessary.
Anxiety also commonly accompanies addiction. Like depression, many anxiety symptoms can be secondary to or exacerbated by addiction, and may stop or lessen considerably with time in recovery. Anxiety can take many forms, but some common presentations are generalized anxiety disorder and panic disorder (a more acute experience of anxiety that can feel like a heart attack). Other presentations include social phobias and performance anxiety. These conditions can occur alone or together in clusters.
With generalized anxiety and panic in particular, benzodiazepines like Xanax or Ativan are often used. These medications are highly addictive, however, so alternatives need to be used to treat addicts. When medication is called for, there are some nonaddicting options. A group of medications called beta blockers (like propranolol) may help. Gabapentin (Neurontin) can helpful in lower doses than usually prescribed. SSRIs such as Zoloft can be helpful for anxiety as well as depression. As mentioned above, acamprosate may help anxiety as well as craving for alcohol.
Sleep problems are especially common in addiction. Again, the medications often used, like the hypnotics (e.g., Ambien) have significant potential for abuse. There are medications that can be helpful and non-addicting, such as Neurontin, trazadone (an atypical antidepressant), and Seroquel (a newer antipsychotic). These uses are off-label (not specifically approved by the FDA) for these medications, and they typically are prescribed in smaller doses than for on-label use and for shorter periods of time, in hopes that sleep patterns are eventually re-established in recovery.
There are other strategies, including certain antidepressants like Remeron or the older tricyclics (e.g., Elavil) that can be tried. If there is a history of sleep problems predating the addiction or if there is suspicion of some kind of sleep disorder (e.g., obstructive sleep apnea), a sleep study is advised.
ADD and ADHD
Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) are not uncommon co-existing psychiatric illnesses with addiction. An interesting study by Volkow et al. (2011) noted that brain imaging (PET scans) supported evidence for disruption of the dopamine reward pathway associated with motivation in ADHD patients. This of course would complicate issues where ADHD co-occurs with addiction, because both conditions affect motivation and reward. It is important therefore to diagnose and treat ADHD if it comes up in addiction. If it is present, there are many treatment alternatives to the potentially addictive stimulants often used to treat ADHD.
Effects of addiction also include inattention and impulsivity, and a period of time in sobriety should be observed to see if these behaviors improve on without treatment. There are those who think that ADD, characterized by inattention with or without hyperactivity, always originates in childhood and may continue into adulthood, and others who believe it can start in adulthood. In either case, while there is good evidence that stimulants like Adderall and Ritalin are quite useful in childhood (and can even reduce risk of addiction in adulthood), there are significant risks for dependence for adults with addiction in using psychostimulants, particularly among females.
We recommend a trial on atomoxitine (Strattera) or bupropion (Wellbutrin). Some serotonin norepinephrine reuptake inhibitors (SNRIs) can help with ADD as well. Recent evidence indicates that methylphenidate (MPH) as a first-line treatment in adults with ADHD is not effective in patients with co-morbid addiction and can put addicts at risk for abuse.
Nonmedication interventions including meditation, neurofeedback, exercise, and cognitive behavioral therapy can also be very useful and have all demonstrated benefits to patients with ADD.
Chronic pain is extremely common in addiction, especially in opiate-dependent people. A condition called “pseudo addiction” happens when someone has real chronic pain and is dependent on opiates only because of the pain. Usually in pseudo addiction, there is no family history of addiction and there is no evidence of connection with the substance, such as a rewarding experience, that transcends pain relief. In some cases, the pain is an excuse for use; in others, the pain is real but may be exaggerated to justify use of opiates. In certain cases, the pain can actually get worse from chronic opiate use, a condition known as “hyperalgesia.”
A careful workup needs to be done to determine the origin of the pain, often with a qualified pain specialist who understands addiction. In cases where there appears to be a legitimate source of pain, non-opiate approaches must be tried. For example, low back pain is the most common chronic pain presentation. For this type of pain, the use of nerve blocks or spinal cord stimulators should be investigated, along with conservative medication management with muscle relaxants (which also have some potential for abuse over time), nonsteroidals (e.g., Celebrex), and Neurontin. Physical therapy usually is a critical long-term strategy as well.
These approaches are useful with many musculoskeletal conditions for which surgery may not be an option. In cases where there is an established need for narcotic analgesia, Suboxone may be a useful and safer pain management strategy.
We have seen a number of true chronic pain conditions improve dramatically with a strong recovery that incorporates a healthy lifestyle—in other words, a positive sobriety. We have also instituted acupuncture and cold laser therapy and are seeing good responses in some of our patients.
Medications—“hardware” interventions—are often necessary to reduce cravings, to block the effects of substances (and reduce potential for relapse), or to treat coexisting conditions like depression or anxiety. They may be necessary for the short term or longer, depending on the individual. In the case of substance blockers or anti-craving medications, use may be necessary for several months to buy time until recovery is firmly established. Some of the more challenging coexisting conditions include chronic pain, attention deficit disorder, and sleep problems. Although these conditions are often treated with potentially addicting medications, they can be managed well without them.