N.  Is Addiction-Focused Pharmacotherapy Indicated?

 

OBJECTIVE

 

Consider appropriateness of addiction-focused pharmacotherapy for all patients.

 

ANNOTATION

 

1.        Consider addiction-focused pharmacotherapy for opioid dependence and/or alcohol dependence as part of a comprehensive treatment plan including addiction-focused psychosocial treatment and pharmacotherapy for co-existing psychiatric conditions (O’Brien & McKay, 1998).

2.        Evaluate indications for pharmacotherapy in all patients with opioid and alcohol dependence (see Tables 3 and 4)

 

Table 3.  Indications for Using Naltrexone and Disulfiram for Alcohol Dependence

Naltrexone

Disulfiram

Alcohol dependence with:

§   Ability to achieve at least 3-5 days of abstinence to rule out the need for detoxification

§   Drinking within the past 30 days and/or reports of craving

§   Most effective when the patient is engaged in addiction-focused counseling

Alcohol dependence with:

§   Abstinence > 24 hours and BAL equal to 0

§   Combined cocaine and alcohol dependence

§   Failure of or contraindication to naltrexone

§   Previous response to disulfiram

§   Patient preference

§   Capacity to appreciate risks and benefits and to consent to treatment

Note:  Most effective with monitored administration (e.g., in clinic or with spouse or probation officer)

 

Table 4.  Indications for Using Naltrexone and Opioid Agonists for Opioid Dependence

Naltrexone

Opioid Agonists:

Methadone and LAAM

Opioid dependence with:

§   Ability to achieve at least 7-10 days of abstinence to rule out the need for detoxification

§   Most effective when the patient is engaged in addiction-focused counseling with monitored administration

§   Opioid dependence > 1year

§   Two or more unsuccessful opioid detoxification episodes within a 12-month period

§   Relapse to opioid dependence within 2 years from OAT discharge

 

 

Please refer to Module P: Addiction-Focused Pharmacotherapy for contraindications and regimen guidelines.

 

DISCUSSION

 

Naltrexone is indicated in the treatment of alcohol dependence and for the blockade of the effects of exogenously administered opioids.  Naltrexone has been shown to reduce drinking and may be particularly effective in preventing full-blown relapses in patients who are alcohol dependent and return to drinking after achieving abstinence (O’Brien & McLellan, 1996; O’Brien & McKay, 1998; Schuckit, 1996; Volpicelli et al., 1997).  Predictors of positive responses have included high levels of alcohol craving at treatment admission, poorer cognitive functioning, and more somatic complaints.  The most consistent predictor of treatment response is better adherence to the treatment protocol and medication regimen.

 

There continue to be questions concerning the efficacy of disulfiram use for alcohol dependence.  Some studies show little efficacy for maintaining complete abstinence at one year (Fuller & Roth, 1979; Fuller et al., 1986, Smith et al., 1998).  Other studies show treatment improvement, especially for highly motivated patients whose disulfiram administration is supervised (Azrin et al., 1982; Chick et al., 1992).  Because of the medical risks of a disulfiram-ethanol reaction (DER) and the risks of disulfiram use itself, disulfiram is generally not considered in a patient who has never received treatment for their alcoholism.  In addition, disulfiram is only appropriate for alcoholics who seek abstinence as their treatment goal.  Disulfiram use should be considered if there is a history of relapse (especially multiple relapses) or if the patient has a past history of successful abstinence while using disulfiram.  Some studies suggest that middle-aged alcohol dependent males with social stability (defined as living with someone or being employed) may be the best candidates (Fuller, 1995).

 

Naltrexone has been shown safe and effective in blocking opiate receptors and has been FDA approved for treatment of opioid dependence since 1983.  It is unpopular among many opioid dependent patients, and few programs encourage chronic opioid addicts to try it (see Module P, Annotation E).

 

New pharmacotherapies for these and other substance use disorders are under investigation (e.g., acamprosate for alcohol dependence and buprenorphine for opioid dependence) and should be considered pending efficacy data and FDA approval.