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Misuse of Prescription Drugs

How can prescription drug addiction be treated?

Years of research have shown that substance use disorders are brain disorders that can be treated effectively. Treatment must take into account the type of drug used and the needs of the individual. Successful treatment may need to incorporate several components, including detoxification, counseling and medications, when available. Multiple courses of treatment may be needed for the patient to make a full recovery.

The two main categories of drug addiction treatment are behavioral treatments (such as contingency management and cognitive-behavioral therapy) and medications. Behavioral treatments help patients stop drug use by changing unhealthy patterns of thinking and behavior; teaching strategies to manage cravings and avoid cues and situations that could lead to relapse; or, in some cases, providing incentives for abstinence. Behavioral treatments, which may take the form of individual, family or group counseling, also can help patients improve their personal relationships and their ability to function at work and in the community.¹

Addiction to prescription opioids can additionally be treated with medications including buprenorphine, methadone and naltrexone (see "Medication-Assisted Treatment (MAT)" below). These drugs can counter the effects of opioids on the brain or relieve withdrawal symptoms and cravings, helping the patient avoid relapse. Medications for the treatment of addiction are administered in combination with psychosocial supports or behavioral treatments, known as medication-assisted treatment (MAT).²

Medication-Assisted Treatment (MAT)

Naltrexone is an antagonist medication that prevents other opioids from binding to and activating opioid receptors. It is used to treat overdose and addiction. An injectable, long-acting form of naltrexone can be a useful treatment choice for patients who do not have ready access to health care or who struggle with taking their medications regularly.

Methadone is a synthetic opioid agonist that prevents withdrawal symptoms and relieves drug cravings by acting on the same brain targets as other opioids such as heroin, morphine and opioid pain medications. It has been used successfully for more than 40 years to treat heroin addiction but is generally available only through specially licensed opioid-treatment programs.

Buprenorphine is a partial opioid agonist — it binds to the opioid receptor but only partially activates it — that can be prescribed by certified physicians in an office setting. Like methadone, it can reduce cravings and is well tolerated by patients. In May 2016, the U.S. Food and Drug Administration (FDA) approved the National Institute on Drug Abuse (NIDA)–supported development of an implantable formulation of buprenorphine. It provides six months of sustained treatment, which will give buprenorphine-stabilized patients greater ease in treatment adherence.

There has been a popular misconception that medications with agonist activity, such as methadone or buprenorphine, replace one addiction with another. This is not the case. Opioid-use disorder is associated with imbalances in brain circuits that mediate reward, decision-making, impulse control, learning and other functions. These medications restore balance to these brain circuits, preventing opioid withdrawal and restoring the patient to a normal affective state to allow for effective psychosocial treatment and social functioning.

While MAT is the standard of care for treating opioid-use disorder, far fewer people receive MAT than could potentially benefit from it. Not all people with opioid-use disorder seek treatment. Even when they seek treatment, they will not necessarily receive MAT. The most recent treatment admissions data available show that only 18 percent of people admitted for prescription opioid-use disorder have a treatment plan that includes MAT.³ However, even if the nationwide infrastructure were operating at capacity, between 1.3 and 1.4 million more people have opioid-use disorder than could currently be treated with MAT due to limited availability of opioid treatment programs that can dispense methadone and the regulatory limit on the number of patients that physicians can treat with buprenorphine.⁴ Coordinated efforts are underway nationwide to expand access to MAT, including a recent increase in the buprenorphine patient limit from 100 patients to 275 for qualified physicians who request the higher limit.⁵

The NIDA is supporting research needed to determine the most effective ways to implement MAT. For example, recent work has shown that buprenorphine-maintenance treatment is more effective than tapering patients off buprenorphine.⁶ Also, starting buprenorphine treatment when a patient is admitted to the emergency department, such as for an overdose, is a more effective way to engage a patient in treatment than referral or brief intervention.⁷ Finally, data have shown that treatment with methadone, buprenorphine or naltrexone for incarcerated individuals improves post-release outcomes.^{8, 9, 10}

Reversing an Opioid Overdose With Naloxone

The opioid overdose-reversal drug naloxone is an opioid antagonist that can rapidly restore normal respiration to a person who has stopped breathing as a result of overdose on prescription opioids or heroin. Naloxone can be used by emergency medical personnel, first responders and bystanders.

Treating Addiction to CNS Depressants

Patients addicted to central nervous system (CNS) depressants such as tranquilizers, sedatives and hypnotics should not attempt to stop taking them on their own. Withdrawal symptoms from these drugs can be severe and — in the case of certain medications — potentially life-threatening.¹¹ Research on treating addiction to CNS depressants is sparse; however, patients who are dependent on these medications should undergo medically supervised detoxification, because the dosage they take should be tapered gradually. Inpatient or outpatient counseling can help individuals through this process. Cognitive-behavioral therapy, which focuses on modifying the patient's thinking, expectations and behaviors while increasing skills for coping with various life stressors, has also been used successfully to help individuals adapt to discontinuing benzodiazepines.¹²

Often CNS depressant misuse occurs in conjunction with the use of other drugs (polydrug use), such as alcohol or opioids. In such cases, the treatment approach should address the multiple addictions.

At this time, there are no FDA-approved medications for treating addiction to CNS depressants, though research is ongoing in this area.

Treating Addiction to Prescription Stimulants

Treatment of addiction to prescription stimulants (such as those commonly prescribed for attention deficit hyperactivity disorder or ADHD) is based on behavioral therapies that are effective for treating cocaine and methamphetamine addiction. At this time, there are no FDA-approved medications for treating stimulant addiction. The NIDA is supporting research in this area.¹³

Depending on the patient, the first steps in treating prescription stimulant addiction may be to taper the drug dosage and attempt to ease withdrawal symptoms. Behavioral treatment may then follow the detoxification process.

References

1. U.S. National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA). (2012, December). Principles of drug addiction treatment: A research-based guide (3rd ed.). Retrieved July 27, 2017, from https://www.drugabuse.gov/
2. Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies — Tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063–2066. doi:10.1056/NEJMp1402780
3. U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality. (2014). Treatment Episode Data Set (TEDS) 2002-2012: National admissions to substance abuse treatment services. Retrieved July 27, 2017, from https://www.samhsa.gov/
4. Jones, C. M., Campopiano, M., Baldwin, G., & McCance-Katz, E. (2015). National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health, 105(8), e55–e63. doi:10.2105/AJPH.2015.302664
5. The White House. (2016, July). Obama administration takes more actions to address the prescription opioid and heroin epidemic [Press Release]. Retrieved July 27, 2017, from https://obamawhitehouse.archives.gov/
6. Fiellin, D. A., Schottenfeld, R. S., Cutter, C. J., Moore, B. A., Barry, D. T., & O'Connor, P. G. (2014). Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: A randomized clinical trial. Journal of the American Medical Association (JAMA) Internal Medicine, 174(12), 1947–1954. doi:10.1001/jamainternmed.2014.5302
7. D'Onofrio, G., O'Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., et al. (2015). Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA, 313(16), 1636. doi:10.1001/jama.2015.3474
8. Gordon, M. S., Kinlock, T. W., Schwartz, R. P., Fitzgerald, T. T., O'Grady, K. E., & Vocci, F. J. (2014). A randomized controlled trial of prison-initiated buprenorphine: Prison outcomes and community treatment entry. Drug and Alcohol Dependence, 142, 33–40. doi:10.1016/j.drugalcdep.2014.05.011
9. Kinlock, T. W., Gordon, M. S., Schwartz, R. P., O'Grady, K., Fitzgerald, T. T., & Wilson, M. (2007). A randomized clinical trial of methadone maintenance for prisoners: Results at 1-month post-release. Drug and Alcohol Dependence, 91(2–3), 220–227. doi:10.1016/j.drugalcdep.2007.05.022
10. Lee, J. D., Friedmann, P. D., Kinlock, T. W., Nunes, E. V., Boney, T. Y., Hoskinson, R. A., Jr., et al. (2016). Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. New England Journal of Medicine, 374(13), 1232–1242. doi:10.1056/NEJMoa1505409
11. Hart, C. L., & Ksir, C. (2013). Drugs, society & human behaviour (15th ed.). New York: McGraw-Hill.
12. Darker, C. D., Sweeney, B. P., Barry, J. M., Farrell, M. F., & Donnelly-Swift, E. (2015). Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane Database of Systematic Reviews, 5, CD009652. doi:10.1002/14651858.CD009652.pub2
13. Ciccarone, D. (2011). Stimulant abuse: Pharmacology, cocaine, methamphetamine, treatment, attempts at pharmacotherapy. Primary Care: Clinics in Office Practice, 38(1), 41–58. doi:10.1016/j.pop.2010.11.004