Opioid Addiction

These include all opioid medications prescribed for pain including heroin, hydrocodone (Vicodin, Norco), oxycodone (Oxycontin, Percocet, etc.), morphine (MS Contin), hydromorphone (Dilaudid), oxymorphone (Opana, Opana ER), meperidine (Demerol), codeine (Tylenol #3), fentanyl (Duragesic, Fentora, etc.), burorphanol (Stadol), levorphanol (levo-dromoran), methadone, etc. 

 

The treatments approved by the FDA include:

1. Suboxone (buprenorphine/naloxone) 2/0.5mg, 8/2mg sublingual films

2. Zubsolv 1.4mg and 5.7mg with 1:4 naloxone sublingual tablet (equivalent to Suboxone dosages) 

3. Bunavail 2.1, 4.2, 6.3mg buprenorphine plus 1:6 naloxone in a microadhesive sublingual form

4. Subutex 2mg and 8mg sublingual tablets 

5. Buprenorphine sublingual generic tablets 2mg and 8mg

6. Buprenorphine/naloxone sublingual generic tablets 2mg and 8mg

7. Probuphine implants 80mg buprenorphine in polyvinyl acetate x 4 once every 6 months

8. Vivitrol injections (naltrexone 380mg IM injection of microspheres once a month

9. Naltrexone oral 60mg tablets (naltrexone) 2 tabs every two days

10. Methadone 5mg, 10mg tablets, 40mg wafers- used long term only in methadone treatment centers

11. The Bridge- an Indiana electrostimulation device with implants in the ear cartilage for 5 days that reportedly significantly eliminates most withdrawal symptoms.  It bridges a person to Vivitrol or Naltrexone.

​

Buprenorphine is a partial agonist/antagonist.  That is, it acts to partially stimulate the receptors while partially blocking other opioids from activating the receptor.  

#1-6 can only be started for the first time if the patient is in overt fulminant withdrawal (Federal law).  If a person receives buprenorphine without being in withdrawal and has recently taking heroin or a prescription opioid, the buprenorphine can precipitate withdrawal symptoms. If buprenorphine is taken without any other opioid taken recently and not in withdrawal, it acts to stimulate the opioid receptor and may reduce pain (if present). In several of these drugs, naloxone (a short acting opioid antagonist not absorbed significantly when taken orally) is used to prevent patients grinding up the films or tablets to inject them intravenously. 

Probuphine (the implantable buprenorphine that is implanted in the arm) is indicated for those on stable doses of less than 8mg buprenorphine sublingual per day (Suboxone form), and realistically 4mg or less buprenorphine per day (Suboxone form).

Vivitrol and Naltrexone actually are opioid antagonists.  If a person has taken any opioid narcotics or painkillers recently and takes either of these drugs, it will precipitate withdrawal.  If a person has these drugs on board already, then taking heroin or a prescription opioid will not lead to a "high" or a rush.  In fact, in most people taking heroin or presciption opioids would have little effect at all, and essentially would be a waste of money. 

Methadone is a full opioid agonist with an exponential increase in effect with increasing dosage due to metabolic self-inhibition: meaning increased dosages of methadone will inhibit its own metabolism by the liver, resulting in much higher of an effect that would be predicted.  The dosages used for pain are typically 5-40mg/day spread out over several doses whereas for addiction treatment, the dosages are 100-300mg/day given all at one time.

​

Not Approved by the FDA but sometimes used for opioid addiction:

1. Butrans patches (buprenorphine)- approximately 1/20 the amount available to the body compared to suboxone- FDA indication is pain treatment

2. Belbuca (buprenorphine)-transbuccal buprenorphine- FDA indication is pain treatment

3. Buprenorphine IM or IV injections- FDA indication is pain treatment

4. Kratom (opioid receptor agonist mitragynine from a plant- illegal in some states and FDA will confiscate shipments).  Not approved by the FDA for any use in the US

5. Phenbut powder reportedly eradicates some of the withdrawal symptoms. Not approved by the FDA for any use

6. Marijuana (does not eradicate all the withdrawal symptoms)-not legal in all states.  Not approved for any use in the US by the FDA, however the Obama administration decided to not enforce federal laws.  Several states have passed "medical marijuana" laws making it available, due to the Obama administrations complicity and Congress's refusal to change federal law. Some states no longer require "medical" uses of marijuana (Colorado). Most people in heroin withdrawal will try marijuana for its sedation effect, but it doesn't help significantly with withdrawal. Am J Addict. 2015 Jun;24(4):323-8

7. Ibugaine (hallucinogen reportedly eradicates withdrawal and craving but is dangerous and illegal).  This drug can cause significant short term issues and may change the brain chemistry long term.  It has not been studied enough to vouch for its safety and should only be taken under direct supervision.  It is not approved by the FDA for any use and is overtly illegal in the US.

8. Sustained release (SR) morphine results in significantly lower craving for heroin scores than methadone treatment J Clin Psychopharmacol. 2015 Apr;35(2):150-7  This suggests SR morphine may be useful as a heroin substitute. Currently in the US, SR Morphine is approved only for pain treatment that is moderate to severe in opioid tolerant patients.

9. Alternative medicine treatments including acupressure, acupuncture, pranic healing, emotional freedom technique (tapping), mindfulness, 12 step yoga, biofeedback, reiki, and others.  The charges for Algos treatments are for these techniques. 

​

The Butrans and Belabuca contain buprenorphine, but usually insufficient amounts to either prevent withdrawal or to continuously treat addiction. Buprenorphine IM or IV is typically used for pain control only, however may be used to rapidly interrupt fulminant withdrawal. Kratom is an opioid, albeit a mild opioid.  It is a leaf or powder and is not approved by the FDA for any use. It is sold in some states, including Florida, but the FDA has declared it is an unapproved substance and has taken action to confiscate shipments. 

​

​

Methamphetamine Addiction

There are no FDA approved drugs for the treatment of methamphetamine addiction, how ever there are some other medications available used off-label with scientific literature support. 

1. Topiramate (Topamax) is an anticonvulsant medication that when given for methamphetamine addiction, shows a significant reduction in methamphetamine use, reduction in methamphetamine cravings, and need for methamphetamine. (Fundam Clin Pharmacol. 2016 Jun;30(3):282-9)

2. Buprenorphine was found to significantly reduce cravings for methamphetamine.  (J Clin Psychopharmacol. 2015 Dec;35(6):724-7)  Methamphetamine is known to activate opioid receptors in the periaquaductal grey of the 4th ventricle area of the brain, therefore using a partial opioid agonist/antagonist would potentially relieve cravings from opioids.

3. Levo-tetrahydropalmatine Pharmacol Biochem Behav. 2016 May;144:67-72 is a naturally occuring derivative of corydalis and stephania.  There is one trial demonstrating some effectiveness  

4. Ritalin, Adderall, and other stimulant drugs have been tried in methamphetamine addicts but with very limited success or only on subscores of tests.  Therefore without any other studies that give firm support for this use, it is currently believed stimulants are inappropiate for the treatment of methamphetamine.

5. Exercise has been shown to increase the D2/D3 striatal dopamine receptor activity that should help reduce the proclivity to addiction.  (Neuropsychopharmacology. 2016 May;41(6):1629-36) 

​

Cocaine Addiction

There are no FDA approved drugs for the treatment of cocaine addiction, however off label use of other medications have been demonstrated to be effective in the treatment of cocaine addiction. 

1. N-acetylcysteine (Mucormist) Neurosci Biobehav Rev. 2015 Aug;55:294-321 has been shown to be of benefit in the treatment of cocaine addiction.  

2. Amphetamine salts extended release being used for ADHD in cocaine addicts had a dose related increased chance of a cocaine free week of OR 2.9 for 60mg and OR 5.5 for 80mg. However, continuous abstinence for 3 weeks was only 30% in the 80mg group vs 7% in the placebo group indicating a partially effective treatment. JAMA Psychiatry. 2015 Jun;72(6):593-602  

3. Biperiden, an antiparkinson's drug, showed reduction in cocaine use but a high drop out rate of 56% vs 80% for placebo.  It may hold some promise.  Eur Neuropsychopharmacol. 2014 Aug;24(8):1196-202

4. There is low level evidence that disulfuram (a dopamine producing agent) has a beneficial effect in the treatment of cocaine addiction.  Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007024  Typical dose 250mg.

5. Contingency management, a psychological counseling technique, is associated with significant improvements compared to the control group in cocaine use  Drug Alcohol Depend. 2013 Jun 1;130(1-3):234-7

​

Antipsychotics have shown in a Cochrane review to not be effective in the treatment for cocaine addiction. Dopamine agonists are not indicated in a Cochrane review with or without psychological therapy.  Topiramate (Drug Alcohol Depend. 2014 Jul 1;140:92-100), lamotrignine, and modafinil were ineffective in reducing cocaine in controlled trials. Modafinil was determined to be effective in one trial but at 300mg a day, it only increased 3 week abstinence from 9% (placebo) to 23% (modafinil), not exactly a resounding success. Drug Alcohol Depend. 2015 Oct 1;155:105-10.  Injectable SR Naltrexone (Vivitrol) does not result in any improvement in cocaine or alcohol addicts Am J Addict. 2014 Nov-Dec;23(6):591-7.  Buspirone was found to worsen cocaine addiction J Clin Psychiatry. 2014 Jul;75(7):757-64.

​

Marijuana Dependency

There are no FDA approved medication treatments for this disorder.  Outcomes for marijuana dependency treatment are typically measured in reduction rather than elimination of use of marijuana, since the vast majority will continue using marijuana long term. For adolescents in an outpatient treatment center and with a diagnosis of high risk cannabis usage, only 11% were abstinent 3 months later, but there was a 36% reduction in dosage taken daily. (Ir Med J. 2015 May;108(5):137-9) There is a case report of using 18mg cannabidiol oil daily that prevented recidivism for marijuana dependency.  A Cochrane review of the literature on psychosocial counseling for marijuana dependence. (Cochrane Database Syst Rev. 2016 May 5) The findings were that on the short term basis (several months) that cognitive behavioral therapy and motivational enhancement therapy were the most useful in decreasing marijuana use, however by 9 months to 1 year afterwards there was no effect, even when continuing in Marijuana Anonymous abstinence groups.  N-acetyl cysteine 1200mg a day for 8 weeks was found in one study to more than double the chance of successful treatment and having a negative baseline initial urine drug screen for marijuana increased the success rate by five times. (J Subst Abuse Treat. 2016 Apr;63:72-7). 

​

One study found Sativex, a spray form of marijuana available in Canada, inhibited withdrawal symptoms but not cravings or marijuana use, since the dosages available were much less than available by smoking marijuana. Dronabinol and lofexidine were ineffective in treatment of marijuana dependency (Drug Alcohol Depend. 2016 Feb 1;159:53-60).  Buspirone (Welbutrin) was ineffective in treatment of marijuana dependence (Drug Alcohol Depend. 2015 Nov 1;156:29-37.)

​

Benzodiazepine Dependency

There are no FDA approved medication treatments for this disorder, however there are substitute medications available to treat the same symptoms for which benzodiazepines are used.  Benzodiazepine dependency is difficult to treat or eradicate because patients taking benzodiazepines (especially alprazolam/Xanax) have both a physical and psychological dependency on the drug.  The withdrawal syndrome for benzodiazepines (sometimes missing even one dose) includes heightened anxiety- the very reason the benzodiazepines are often prescribed (much longer than the 2 weeks they are supposed to be used).  People are very resistant to reduction in dosage however those that have gradually withdrawn from the drugs over a 4-6 month period remark that it is though "a veil had been lifted from their eyes".  The elderly become much more interactive with their families and friends, and many of the severe memory issues and unstable walking patterns resolve once off benzodiazepines.

Treatment Options:

• Conversion to a long acting benzodiazepine then very gradually wean off

• Use of buspirone (Buspar) if needed for anxiety.  This medication may be used long term. 

• Use of Vistaril (hydroxyzine) as a substitute for low dose benzodiazepines after weaning down on the dosage

• SRNI- proven to help with anxiety in most: desvenlafaxine(Pristiq),  duloxetine (Cymbalta), venlafaxine (Effexor)

• Anticonvulsants may be potentially useful (gabapentin, topiramate, etc.)

• Propranolol may be potentially useful (slows the heartrate)

​

   Pregabalin 300-600mg per day was used during and for 12 weeks after a taper of alprazolam initially 1-4mg per day, tapered at 25% per week.  The pregabalin group had 53% complete the study and only 37% of the placebo group completed the study.  Of those completing the study, 51% of the pregabalin group and 37% of the placebo remained benzodiazepine free.  The anxiety scores decreased in the pregabalin group and increased in the placebo group. This study demonstrates the profound psychological dependency patients taking benzodiazepines and how difficult it is to eradicate benzodiazepines.  Overall it appears with pregabalin treatment during and after alprazolam withdrawal, that minimally only about 25% remain free of benzodiazepines. (J Psychopharmacol. 2012 Apr;26(4):461-70)

   Pregabalin was used (mean 315mg/day range 150-450mg) in an open uncontrolled 12 week benzodiazepine taper of several benzodiazepines taken long term.  At the end of 12 weeks 50% had urine drug screens free of benzodiazepines. (Eur Psychiatry. 2012 May;27(4):301-7)

   Pregabalin (Lyrica-mean dose 225mg/day) compared to sertraline (Zoloft-mean dose 150mg/day) was found to be equally effective for the treatment of generalized anxiety disorders but had a much more rapid onset of effect (2-3 days vs 14 days).  Both groups had CBT for 8 weeks. The Hamilton score of anxiety reduced from 24 to 14 in both groups. There was a 13% incidence of dizziness and 10% sedation in the pregabalin group and 13% nausea in the sertraline group. (Eur Rev Med Pharmacol Sci. 2015;19(11):2120-4.)