Drugs used in treatment of addiction

What is Addiction? It is well known that the initial decision to use drugs is voluntary Addiction is a chronic, relapsing brain disease characterized by compulsive behavior of a person to continue taking drugs despite their many adverse health and negative consequences (craving) But what is addiction? We now know that while the initial decision to use drugs is voluntary, drug addiction is a disease of the brain that compels a person to continue taking drugs despite their many adverse health and life consequences.

Drugs of addiction Stimulants - stimulate the central nervous system - amphetamines, cocaine, nicotine Depressants - depress the CNS - alcohol, barbiturates, benzodiazepines Analgesics - powerful painkillers - from opium poppy , morphine, heroin Hallucinogens - dramatically alter perception - LSD, cannabis, Marijuana

of Addiction No single treatment is appropriate for all individuals Pharmacological (medications) Psychological Behavioral Therapies Medical and Social Services Family Services; solving legal problems Matching Patients to Individual Needs No single treatment is appropriate for all individuals. Matching treatment setting, interventions, and services to each individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual’s drug use and any associated medical, psychological, social, vocational, and legal problems.  

Aim of pharmacological treatment Treatment of withdrawal (“detox”) Medications used to alleviate withdrawal symptoms Treatment of psychiatric symptoms Reduction of cravings Substitution therapy Other forms of relapse prevention/harm reduction: aversive conditions if use, restore impulse control, Prevention: use of psych med that may delay or prevent onset of SUD: ex: evidence of tx of ADHD may delay onset of SUD in adolescence, tx of ADHD with bupropion may reduce rates of initiation of tobacco use. Replacement therapy: NRT, methadone, buprenorphine

Medications for Drug Addiction Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Alcohol: Naltrexone, Disulfiram, Acamprosate Opiates: Naltrexone, Methadone, clonidine levo-alpha-acetylmethadol (LAAM) Nicotine: Nicotine replacement (gum, patches, spray), bupropion Stimulants: [None to date] Medications for Drug Addiction Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethadol (LAAM) are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring addiction to alcohol. For persons addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For patients with mental disorders, both behavioral treatments and medications can be critically important.  

Treatment of Chronic Alcoholism Hospitalization, psychotherapy and nutritional therapy may be needed. Drug therapy includes: BZs (e.g. diazepam) are used to prevent alcohol withdrawal symptoms. They are preferred over barbiturates because of their wide margin of safety. The dose must be tapered slowly over several weeks.

Disulfiram The drug given by itself to nondrinkers has little effects however, it causes extreme discomfort to patients who drink alcohol (Flushing, throbbing headache, nausea, vomiting, sweating, hypotension and confusion). Disulfiram acts by inhibiting aldehyde dehydrogenase thus, alcohol is metabolized as usual but acetaldehyde accumulates. Acetaldehyde will form the toxic intermediates; methanol and formaldehyde.

Naltrexone is an  opioid receptor antagonist used primarily in the management of  alcohol dependence and opioid dependence (blocking the drugs’ euphoric effects) Acamprosate stabilize the chemical balance in the brain by antagonizing glutamatergic N-methyl-D-aspartate recepotors and  antagonizing gamma aminobutyric acidn(GABAA) receptors

Treatment of Morphine Addiction Hospitalization

Drug therapy Hypnotics to help sleeping. Naltrexone helps patients overcome opioid addiction by blocking the drugs’ euphoric effects.  Gradual withdrawal of morphine to a stabilizing dose just sufficient to prevent withdrawal symptoms. Substitution therapy with methadone which is a long acting opioid, (1 mg methadone to 4 mg morphine for 1 week)

Then, methadone is withdrawn gradually over a period of 3 days. Why Methadone?? Synthetic opioid agonist , Analgesic Quick absorption, slow elimination Effects last 24 hours; once-daily dosing maintains constant blood level Prevents withdrawal and reduces craving

Levo-α-acetylmethadol levo-α-acetylmethadol (LAAM) is a synthetic opioid similar in structure to methadone. It has a long duration of action due to its active metabolites. LAAM is indicated as a second-line treatment for the treatment of opioid dependence if patients fail to respond to methadone.

Medications for Sedative-Hypnotic Dependence Taper: slowly decrease dose to minimize withdrawal symptoms May first convert to longer-acting agent Role for anticonvulsants Use non-addictive medications for residual anxiety symptoms (SSRIs and other antidepressants)

Treatment of Stimulant Dependence Symptomatic treatment Behavioral therapies effective for treating stimulant addiction. There are no proven medications for the treatment of stimulant addiction. Slowly decrease dose Medications to treat withdrawal symptoms Anxiety Depression * NIDA

Medications for Stimulant Dependence Medications used to treat stimulant-induced psychiatric symptoms: Antidepressants Antipsychotics Anti-anxiety agents Medications to treat agitation, violence ER and outpatient settings Medications to treat co-occurring psychiatric disorders

Attention deficit hyperactivity disorder (ADHD)

ADHD more difficulty focusing, controlling actions, and remaining still or quiet than other people who are the same age in children. 

Environmental factors Neuroanatomical neurochemical ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies Environmental factors Neuroanatomical neurochemical ADHD ADHD is most likely caused by a complex interplay of factors Biologic factors that predispose an individual for ADHD include post-traumatic or infectious encephalopathy, lead poisoning, and fetal alcohol syndrome Environmental influences include abuse or neglect, family adversity, and situational stress Emerging literature provides support for the hypothesis that abnormalities in frontal networks or frontal-striatal dysfunction and catecholamine dysregulation are involved Family and twin studies reveal compelling data regarding the genetic origin of ADHD; and recent advances in neuroimaging techniques have promoted closer study of neuroanatomic correlates CNS insults Genetic origins

ADHD symptoms

Stimulants for ADHD 1st line treatment currently available include short-, intermediate-, and long-acting drugs. starts with low dose then increase the dose

Methylphenidate Ritalin CNS stimulant increases attention, decreases impulsiveness, and hyperactivity Methylphenidate blocks the transporter for dopamine and norepinephrine Methylphenidate * WebMD

Amphetamines Adderall Dopamine (DA) and Norepinephrine (NE) modulating agent Adderall is a combination of stimulants (amphetamine and dextroamphetamine). It increases the ability to pay attention, focus, and control behavior problems. This drug may also be used to treat certain sleeping disorders (narcolepsy).

Antidepressants 2nd line treatment TCAs (Imipramine, Desipramine) Bupropion (targets dopamine and norepinephrine) most effective for treatment of ADHD combined with depression.) Venlafaxine

Atomoxetine Non stimulant drug a selective norepinephrine reuptake inhibitor (NRI) is approved for use in children, adolescents, and adults.  Excellent for inattentiveness

Clonidine high blood pressure medication can manage ADHD symptoms of aggressive behavior, impulsions, hyperactivity It is classified as a centrally acting α2 adrenergic agonist.

Best Wishes Guanfacine Guanfacine belongs to a class of medications called centrally acting alpha2A-adrenergic receptor agonists. Used for hypertension