PAC 610 Module 6 Medications for Substance Use Disorders Example

Not Trading One Drug for Another: The Evidence for Medications in Opioid and Alcohol Use Disorders

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 610: Psychopharmacology

Instructor Name

Month Day, Year

Not Trading One Drug for Another: The Evidence for Medications in Opioid and Alcohol Use Disorders

Tyler and Monique, two clients of the made-up Ridgeview Recovery Center in Knoxville, bring the questions of this module into focus. Tyler, twenty-nine, has taken buprenorphine for a year after several overdoses. He works, pays rent and has not used heroin in eleven months. His parents, who paid for two residential stays that did not last, want him to "get off drugs completely" and have been urging him to taper. Monique, forty-five, has an alcohol use disorder and has been abstinent for three weeks after detoxification; the nurse practitioner has suggested naltrexone, and Monique is unsure. This paper reviews the medications and evidence that bear on their decisions.

The Medications

Opioid Medications: Retention and Use

Mattick et al. (2014) reviewed randomized trials of buprenorphine maintenance for opioid dependence in a Cochrane review. Compared with placebo, buprenorphine at medium and high doses kept more people in treatment and, at high doses, reduced illicit opioid use. Compared with methadone at flexible doses, buprenorphine retained somewhat fewer people in treatment, while the two performed similarly on reducing opioid use among those who stayed. The authors concluded that both are effective maintenance treatments, with methadone holding a modest advantage in retention.

Opioid Medications and Death

Sordo et al. (2017) pooled cohort studies following people with opioid dependence in and out of methadone and buprenorphine treatment. All-cause mortality was several times higher out of treatment than in it. The first weeks after leaving treatment were particularly dangerous, as was the first month of starting methadone. The authors concluded that keeping people in treatment longer could prevent many deaths. For Tyler, whose tolerance would fall after a taper, this evidence is directly relevant.

Naltrexone Versus Buprenorphine

Lee et al. (2018) randomly assigned adults entering inpatient detoxification to extended-release naltrexone or buprenorphine-naloxone and followed them for twenty-four weeks. Starting naltrexone proved the major hurdle: because it requires full detoxification first, a substantial share of those assigned to it never received their first injection, whereas nearly everyone assigned to buprenorphine began treatment. Counting every person randomized, the naltrexone arm relapsed more often. Among those who did start their assigned medication, relapse rates were similar. The trial shows that both medications can work and that the practical difficulty of starting naltrexone matters greatly.

Why So Few People Receive Them

Despite this evidence, many people with opioid use disorder never receive methadone or buprenorphine, and fewer still with alcohol use disorder receive medication. Barriers include too few prescribers, rules that require daily clinic visits for methadone, stigma within treatment programs and among families, and the belief, held by some clients themselves, that recovery on medication is not real recovery. Counselors work at the point where several of these barriers meet: they hear clients' doubts, meet their families and shape the culture of programs.

Alcohol Medications

Jonas et al. (2014) reviewed medications for alcohol use disorders in outpatient settings. Each of the two main drugs, acamprosate and naltrexone tablets at 50 milligrams a day, lowered the chance of drinking again. The authors estimated that about twelve people would need to take acamprosate, and about twenty naltrexone, for one to avoid any return to drinking; for naltrexone, about twelve people would need treatment for one to avoid a return to heavy drinking. Direct comparisons found no clear difference between the two. Evidence for disulfiram in well-controlled trials was weak. The authors noted that these medications are used by only a small fraction of people with alcohol use disorders.

The Substitution Objection

Tyler's parents voice a common belief: that buprenorphine merely trades one addiction for another. The distinction between physical dependence and addiction answers it. Physical dependence, the body's adaptation that causes withdrawal when a drug stops, occurs with many medications, including some for blood pressure and depression. Addiction involves compulsive use despite harm, loss of control and a life organized around obtaining and using a drug. At a stable dose, buprenorphine relieves craving and withdrawal without producing the cycle of intoxication and withdrawal that drove Tyler's heroin use. His working, paying rent and staying alive are the signs of recovery.

Applying the Evidence to Tyler

Tyler's counselor should not tell him to stay on buprenorphine or to taper; that decision belongs to Tyler and his prescriber. But the counselor can make sure the decision is informed. With his permission, the counselor can meet with Tyler and his parents to explain the difference between dependence and addiction and share what the research shows about mortality after leaving treatment. The counselor can explore what Tyler himself wants. If he chooses to taper someday, it should be slow, planned with the prescriber and paired with overdose prevention, including naloxone at home.

Applying the Evidence to Monique

Monique is a reasonable candidate for naltrexone or acamprosate, and the counselor can help her weigh them with the nurse practitioner. She should know that the benefits are real but modest and that the medication works best alongside counseling and support. If she ever needs opioid pain medication, she must tell the prescriber she takes naltrexone. Her counselor can also address any sense that taking medication means she has failed at recovery, since the evidence shows it is a tool many people use successfully.

Conclusion

Medications for opioid use disorder keep people in treatment, reduce illicit use and, most importantly, reduce death; naltrexone can work but is harder to start. Medications for alcohol use disorder offer modest, real benefits. Counselors can help clients and families understand this evidence, answer the substitution objection with the distinction between dependence and addiction and support informed decisions made with prescribers.

References

Jonas, D. E., Amick, H. R., Feltner, C., Bobashev, G., Thomas, K., Wines, R., Kim, M. M., Shanahan, E., Gass, C. E., Rowe, C. J., & Garbutt, J. C. (2014). Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. JAMA, 311(18), 1889-1900. https://doi.org/10.1001/jama.2014.3628

Lee, J. D., Nunes, E. V., Novo, P., Bachrach, K., Bailey, G. L., Bhatt, S., Farkas, S., Fishman, M., Gauthier, P., Hodgkins, C. C., King, J., Lindblad, R., Liu, D., Matthews, A. G., May, J., Peavy, K. M., Ross, S., Salazar, D., Schkolnik, P., ... Rotrosen, J. (2018). Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): A multicentre, open-label, randomised controlled trial. The Lancet, 391(10118), 309-318. https://doi.org/10.1016/S0140-6736(17)32812-X

Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, (2), Article CD002207. https://doi.org/10.1002/14651858.CD002207.pub4

Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, L., Ferri, M., & Pastor-Barriuso, R. (2017). Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. BMJ, 357, j1550. https://doi.org/10.1136/bmj.j1550