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Evidence-Based Approaches to Drug Addiction Treatment
| Each approach to drug treatment is designed to address certain aspects of drug addiction and its consequences for the individual, family, and society |
This section presents several examples of treatment approaches and components that have an evidence base supporting their efficacy. Each approach is designed to address certain aspects of drug addiction and its consequences for the individual, family, and society. Some of the approaches are intended to supplement or enhance existing treatment programs, and others are fairly comprehensive in and of themselves.
The following is not a complete list of efficacious evidence-based treatment approaches. More are under development as part of our continuing support of treatment research.
Pharmacotherapies
Opioid Addiction
Methadone
Methadone maintenance treatment is usually conducted in specialized settings (e.g., methadone maintenance clinics). These specialized treatment programs offer the long-acting synthetic opioid medication methadone at a dosage sufficient to prevent opioid withdrawal, block the effects of illicit opioid use, and decrease opioid craving.
Combined with behavioral treatment: The most effective methadone maintenance programs include individual and/or group counseling, as well as provision of or referral to other needed medical, psychological, and social services. In a study that compared opioid-addicted individuals receiving only methadone to those receiving methadone coupled with counseling, individuals who received only methadone showed some improvement in reducing opioid use; however, the addition of counseling produced significantly more improvement, and the addition of onsite medical/psychiatric, employment, and family services further improved outcomes.
Further Reading:
Dole, V.P.; Nyswander, M.; and Kreek, M.J. Narcotic blockade. Archives of Internal Medicine 118:304-309, 1996.
McLellan, A.T.; Arndt, I.O.; Metzger, D.; Woody, G.E.; and O'Brien, C.P. The effects of psychosocial services in substance abuse treatment. JAMA 269(15):1953-1959, 1993.
Woody, G.E., et al. Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry 40:639-645, 1983.
Buprenorphine
Buprenorphine is a partial agonist (it has both agonist and antagonist properties) at opioid receptors that carries a low risk of overdose. It reduces or eliminates withdrawal symptoms associated with opioid dependence but does not produce the euphoria and sedation caused by heroin or other opioids.
In 2000, Congress passed the Drug Addiction Treatment Act, allowing qualified physicians to prescribe Schedule III, IV, and V medications for the treatment of opioid addiction. This created a major paradigm shift that allowed access to opioid treatment in general medical settings, such as primary care offices, rather than limiting it to specialized treatment clinics.
Buprenorphine was the first medication to be approved under the Drug Addiction Treatment Act and is available in two formulations: Subutex® (a pure form of buprenorphine) and the more commonly prescribed Suboxone® (a combination of buprenorphine and the opioid antagonist naloxone). The unique formulation with naloxone produces severe withdrawal symptoms when addicted individuals inject it to get high, lessening the likelihood of diversion.
Physicians who provide office-based buprenorphine treatment for detoxification and/or maintenance treatment must have special accreditation. These physicians are also required to have the capacity to provide counseling to patients when indicated or, if they do not, to refer patients to those who do.
Office-based treatment of opioid addiction is a cost-effective approach that increases the reach of treatment and the options available to patients. Many patients have life circumstances that make office-based treatment a better option for them than specialty clinics. For example, they may live far away from treatment centers or have working hours incompatible with the clinic hours. Office-based addiction treatment is being offered by primary care physicians, psychiatrists, and other specialists, such as internists and pediatricians.
Patients stabilized on adequate, sustained dosages of methadone or buprenorphine can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. Patients stabilized on these medications can also engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation.
| Patients stabilized on adequate, sustained dosages of methadone or buprenorphine can hold jobs, avoid crime and violence, and reduce their exposure to HIV. |
Further Reading:
Fiellin, D.A., et al. Counseling plus buprenorphinenaloxone maintenance therapy for opioid dependence. The New England Journal of Medicine 355(4):365-374, 2006.
Fudala P.J., et al. Buprenorphine/Naloxone Collaborative Study Group: Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. The New England Journal of Medicine 349(10):949-958, 2003.
Kosten, T.R., and Fiellin, D.A. U.S. National Buprenorphine Implementation Program: Buprenorphine for office-based practice: Consensus conference overview. The American Journal on Addictions 13(Suppl. 1):S1-S7, 2004.
McCance-Katz, E.F. Office-based buprenorphine treatment for opioid-dependent patients. Harvard Review of Psychiatry 12(6):321-338, 2004.
Naltrexone
Naltrexone is a long-acting synthetic opioid antagonist with few side effects. An opioid antagonist blocks opioids from binding to their receptors and thereby prevents an addicted individual from feeling the effects associated with opioid use. Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although initiation of the treatment often begins after medical detoxification in a residential setting. To prevent withdrawal symptoms, individuals must be medically detoxified and opioid-free for several days before taking naltrexone. The medication is taken orally either daily or three times a week for a sustained period. When used this way, naltrexone blocks all the effects, including euphoria, of self-administered opioids. The theory behind this treatment is that the repeated absence of the desired effects and the perceived futility of using the opioid will gradually diminish opioid craving and addiction. Naltrexone itself has no subjective effects (that is, a person does not perceive any particular drug effects) or potential for abuse, and it is not addictive. However, patient noncompliance is a common problem. Therefore, a favorable treatment outcome requires an accompanying positive therapeutic relationship, effective counseling or therapy, and careful monitoring of medication compliance. Many experienced clinicians have found naltrexone best suited for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances. Professionals, parolees, probationers, and prisoners in work-release status exemplify this group.
Combined with behavioral treatment: Motivational incentives, such as the offering of prizes or rewards for maintaining abstinence, have been shown to enhance the treatment compliance and efficacy of naltrexone for opioid addiction.
Further Reading:
Carroll, K.M., et al. Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: Efficacy of contingency management and significant other involvement. Archives of General Psychiatry 58(8):755- 761, 2001.
Cornish, J.W., et al. Naltrexone pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment 14(6):529-534, 1997.
Greenstein, R.A.; Arndt, I.C.; McLellan, A.T.; and O'Brien, C.P. Naltrexone: A clinical perspective. Journal of Clinical Psychiatry 45(9, Part 2):25-28, 1984.
Preston, K.L.; Silverman, K.; Umbricht, A.; DeJesus, A.; Montoya, I.D.; and Schuster, C.R. Improvement in naltrexone treatment compliance with contingency management. Drug and Alcohol Dependence 54(2):127-135, 1999.
Resnick, R.B., and Washton, A.M. Clinical outcome with naltrexone: Predictor variables and followup status in detoxified heroin addicts. Annals of the New York Academy of Sciences 311:241-246, 1978.
Tobacco Addiction
Nicotine Replacement Therapy (NRT)
A variety of formulations of nicotine replacement therapies now exist, including the transdermal nicotine patch, nicotine spray, nicotine gum, and nicotine lozenges. Because nicotine is the main addictive ingredient in tobacco, the rationale for NRT is that stable low levels of nicotine will prevent withdrawal symptoms—which often drive continued tobacco use—and help keep people motivated to quit.
Bupropion (Zyban®)
Bupropion was originally marketed as an antidepressant (Wellbutrin®). It has mild stimulant effects through blockade of the reuptake of catecholamines, especially norepinephrine and dopamine. A serendipitous observation among depressed patients was the medication's efficacy in suppressing tobacco craving, promoting cessation without concomitant weight gain. Although bupropion's exact mechanisms of action in facilitating smoking cessation are unclear, it has FDA approval as a smoking cessation treatment.
Varenicline (Chantix®)
Varenicline is the most recently FDA-approved medication for smoking cessation. It acts on a subset of nicotinic receptors (alpha-4 beta-2) thought to be involved in the rewarding effects of nicotine. Varenicline acts as a partial agonist/antagonist at these receptors—this means that it mildly stimulates the nicotine receptor, but not sufficiently to allow the release of dopamine, which is important for the rewarding effects of nicotine. As an antagonist, varenicline also blocks the ability of nicotine to activate dopamine, interfering with the reinforcing effects of smoking, thereby reducing cravings and supporting abstinence from smoking.
Combined With Behavioral Treatment
Each of the above pharmacotherapies is recommended for use in combination with behavioral interventions, including group and individual therapies, as well as telephone quitlines. Through behavioral skills training, patients learn to avoid high-risk situations for smoking relapse and to plan strategies to cope with such situations when necessary. Coping techniques include cigarette refusal skills, assertiveness, and time management skills that patients practice in treatment, social, and work settings. Combined treatment is urged because behavioral and pharmacological treatments are thought to operate by different yet complementary mechanisms that can have additive effects. By dampening craving intensity, medications can give patients a leg up on enacting new strategies and skills.
Further Reading:
Alterman, A.I.; Gariti, P.; and Mulvaney, F. Short- and long-term smoking cessation for three levels of intensity of behavioral treatment. Psychology of Addictive Behaviors 15:261-264, 2001.
Cinciripini, P.M.; Cinciripini, L.G.; Wallfisch, A.; Haque, W.; and Van Vunakis, H. Behavior therapy and the transdermal nicotine patch: Effects on cessation outcome, affect, and coping. Journal of Consulting and Clinical Psychology 64:314-323, 1996.
Hughes, J.R. Combined psychological and nicotine gum treatment for smoking: A critical review. Journal of Substance Abuse 3:337-350, 1991.
Jorenby, D.E., et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: A randomized controlled trial. The Journal of the American Medical Association 296(1):56-63, 2006.
Stitzer, M. Combined behavioral and pharmacological treatments for smoking cessation. Nicotine & Tobacco Research 1:S181-S187, 1999.
Alcohol Addiction
Naltrexone
Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. It reduces relapse to heavy drinking, defined as four or more drinks per day for women and five or more for men. Naltrexone cuts relapse risk during the first 3 months by about 36 percent but is less effective in helping patients maintain abstinence.
Acamprosate
Acamprosate (Campral®) acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria. Acamprosate has been shown to help dependent drinkers maintain abstinence for several weeks to months, and it may be more effective in patients with severe dependence.
Disulfiram
Disulfiram (Antabuse®) interferes with degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. The utility and effectiveness of disulfiram are considered limited because compliance is generally poor. However, among patients who are highly motivated, disulfiram can be effective, and some patients use it episodically for high-risk situations, such as social occasions where alcohol is present. It can also be administered in a monitored fashion, such as in a clinic or by a spouse, improving its efficacy.
Topiramate
Topiramate is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission. Its precise mechanism of action in treating alcohol addiction is not known, and it has not yet received FDA approval. Topiramate has been shown in two randomized, controlled trials to significantly improve multiple drinking outcomes, compared with a placebo. Over the course of a 14-week trial, topiramate significantly increased the proportion of patients with 28 consecutive days of abstinence or non-heavy drinking. In both studies, the differences between topiramate and placebo groups were still diverging at the end of the trial, suggesting that the maximum effect may not have yet been reached. Importantly, efficacy was established in volunteers who were drinking upon starting the medication.
Combined With Behavioral Treatment
While a number of behavioral treatments have been shown to be effective in the treatment of alcohol addiction, it does not appear that an additive effect exists between behavioral treatments and pharmacotherapy. Studies have shown that getting help is one of the most important factors in treating alcohol addiction, compared to getting a particular type of treatment.
Further Reading:
Anton, R.F.; O'Malley, S.S.; Ciraulo, D.A.; et al., for the COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA 295(17):2003-2017, 2006.
National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide, Updated 2005 Edition. Bethesda, MD: NIAAA, updated 2005. Available at http://www.niaaa.nih.gov/Publications/ EducationTrainingMaterials/guide.htm.
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