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The Role of Medication in Addictions Treatment

A. Tom Horvath, Ph.D., ABPP, Kaushik Misra, Ph.D., Amy K. Epner, Ph.D., and Galen Morgan Cooper, Ph.D. , edited by C. E. Zupanick, Psy.D.

Medications are used adjust brain chemistry. This adjustment is intended to repair damage caused by repeated stimulation from addictive substances or activities. The goal is to restore or enhance the brain's healthy functioning. By doing so, drug use is not so compelling. These goals can be accomplished in several different ways. Goals 1-4 are most applicable to substance addictions. Goals 4-5 are applicable to both substance and activity addictions.

pile of pills1) Diminish the appealing reward of a drug by causing a person to become sick if they use it (e.g., Antabuse®).

2) Reduce or block the effect of a drug so that the experience of drug is no longer pleasant (e.g., naltrexone).

3) Provide a substitute for the original substance that is not nearly as enjoyable as the original, but that prevents highly unpleasant withdrawal symptoms from occurring (buprenorphine, methadone).

4) Restore healthy neurophysiological functioning. The addictive substance or activity will no longer be needed as a form of self-medication. For example, medications that treat depression can alleviate the need to use alcohol to feel better (momentarily anyway). Similarly, correct for neurophysiological changes that resulted from chronic drug use, or addictive activities.

5) Prevent or diminish powerful cravings that cause people to resume drug use or an addictive activity, after a period of cessation.

In the Biology of addiction section we mentioned the development of an addiction is largely due to the influence of our genetics on brain functioning. In effect, our unique genetics may make it more likely that our brains can become hijacked by addiction. This makes some people more prone to develop an addiction than others.

Because biology plays such a large role in the development of addiction, it is tempting to hope for a biological cure in the form of medication. The United States federal government invests millions of dollars on research each year. The hope is this research will lead to a promising treatment for addiction. Unfortunately, it is unlikely that medication alone will result in any significant reduction in addiction. This is because while our biology greatly influences whether or not an addiction develops, our psychology determines whether we are motivated to do anything about it. Thus, addiction development is fundamentally a biological problem of genetics. Addiction recovery is fundamentally a psychological problem of motivation. Even if a magic pill is developed, a person must be sufficiently motivated to take this medication. We will discuss the important role of motivation in another section.

Nonetheless, medication can be a highly effective tool. This is particularly true for motivated individuals. Medications can make recovery efforts more comfortable, and make addiction less rewarding. Thus, medication can be an important, beneficial addition to someone's recovery program. Even when a medication is effective, studies find that medication plus counseling is superior to medication alone.

Medications for addictions treatment are constantly under development. Many medications that were originally created for other purposes have proven to be helpful in addictions recovery. When the FDA approves a medication, the approval is limited to a specific purpose. The FDA limits the way a drug company may market a drug. The FDA does not limit physicians. Generally, physicians may prescribe any medication for any purpose. This is true even when the prescription is not FDA-approved for that purpose.

Sometimes a physician writes a prescription for a purpose that is different from its FDA-approved purpose. In this case, the prescription is said to be written "off-label." For instance, a physician might prescribe Antabuse® to treat cocaine dependence. This would be "off-label" because Antabuse® is only FDA-approved for the treatment of alcohol problems. Although off-label use is permitted by physicians, pharmaceutical companies are not permitted to promote off-label use. If an off-label use widely occurs, the pharmaceutical company would be financially motivated to gain FDA approval for that purpose. Your physician should inform you if s/he suggests an off-label use of a medication. However, in addiction medicine, and in medicine generally, off-label use is rather common. Consumer Reports (2007) suggests some questions to ask if you are offered an off label prescription.

If you are curious about strengthening your recovery efforts with medication, it is wise to consult with a specialist in addiction medicine. There are two resources for locating such a specialist. One option is to search for a physician who is board certified in addiction medicine by the American Board of Addiction Medicine (ABAM). You can search for a board certified physician on their website. However, there are also highly qualified addictions specialists who have not become board-certified. The American Society of Addiction Medicine (ASAM)  turned over their certification process to ABAM in 2009. You can search their website to find members in your geographic area.