Using medications in the treatment of addiction

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Fixing the Fix

  • Courtney Humphries
JANUARY 22, 2015

The 13th Step?

More and more Doctors who treat addiction see it as a chronic disease. “People who suffer from addiction require long-term, perhaps indefinite, follow-up treatment that often requires the use of medications,” says Jason Jerry, MD, an addiction psychiatrist at the Cleveland Clinic’s Alcohol and Drug Recovery Center. Most people never seek treatment at all; according to the National Institute on Drug Abuse, an estimated 22.7 million Americans had a drug or alcohol use problem in 2013, and only 2.5 million underwent treatment at a specialty facility. Those who do get treatment often wait until addiction has caused damage—an arrest, a lost job, an overdose, a broken family.

While studies find that many substance abusers eventually overcome their problem without treatment, others have a much harder time changing their behavior. “People usually have to make multiple quit attempts,” says Mark Willenbring, MD, founder and CEO of Alltyr addiction treatment clinic in St. Paul, Minn. His clinic emphasizes ongoing long-term care, similar to what patients with diabetes, heart disease, or arthritis would receive.

Those who treat addictions are increasingly recognizing that medications can help people make the changes they need to make. A handful of drugs are currently available for opioid, alcohol, and tobacco dependency, but not specifically for dependency on cocaine, methamphetamines, or marijuana. Methadone and buprenorphine (Subutex, Suboxone) help people overcome opioid addictions by mimicking the drug to reduce withdrawal symptoms and cravings, but without the high. Naltrexone (Revia, Vivitrol), which blocks the effects of opiates, is used to treat opiate addictions as well as alcohol dependence as a daily pill or monthly injection. Studies on its effectiveness as a treatment for alcoholism have been equivocal, though, and suggest it works best in those with the strongest alcohol cravings and in people of specific genetic backgrounds. Acamprosate (Campral) can also help reduce alcohol cravings, and disulfiram (Antabuse) has been used to treat severe alcoholism since the 1920s, but because it makes people feel ill when they have alcohol, some fail to keep taking it.

Medications like these have been controversial in the addiction treatment community because of the persistent belief that addicts must exercise their own free will to overcome the habit. But Marina Picciotto, PhD, a neuroscientist at Yale University, says that science shows just how challenging that is. “The ability to change behavior is much, much harder for an addict,” she says. “You have to understand your free will as an expanding or contracting balloon.” Addiction actually diminishes the ability to make better choices.

Various addictive substances affect the brain differently, but they all hijack a set of brain regions called the reward circuit, which releases the chemical signal dopamine—the “high” one gets from a drug like cocaine. “Once you’ve experienced cocaine many times, the system adapts,” Picciotto says. You develop tolerance to the drug’s effects, and the dopamine system stops functioning properly—it loses the ability to respond to normal pleasures.

Current medications for addiction work by targeting the reward circuit, either by blocking the effects of the drug or controlling cravings for it. Ibudilast, a medication developed in Japan as an anti-inflammatory, could actually repair the reward system in a different way. Researchers at the University of California, Los Angeles are testing the drug for methamphetamine addiction. Keith Heinzerling, MD, the addiction physician at UCLA who is leading the meth study, says that animal research finds that the massive release of dopamine that methamphetamine stimulates is damaging to brain cells and causes an inflammation response in the brain. Ibudilast is thought to calm that inflammation by reducing the activity of microglia, immune cells found only in the brain. “It’s essentially an anti-inflammatory medication for the brain’s immune system,” Dr. Heinzerling says. A team from Columbia University is also leading a phase 2 study of ibudilast in heroin users. The drug, which is also being tested as a multiple sclerosis treatment, was given fast-track status by the Food and Drug Administration, which helps speed a medication through clinical testing if it shows promise for treating serious conditions.

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