OVERVIEW OF MEDICATIONS TO TREAT ADDICTION IN …...20 • Contraindications: severe angina, post-myocardial infarction, pregnancy, hypersensitivity • Side Effects: minimal except

OVERVIEW OF

MEDICATIONS TO

TREAT ADDICTION IN

PRIMARY CARE

Prepared by

CASAColumbia®

February 2014

© CASAColumbia 2014

Outline

• Introduction

• Addiction Involving:

− Tobacco/Nicotine

− Alcohol

− Opioids

− Other Drugs

• Further Considerations

2


3

INTRODUCTION


Addiction

For background

information on addiction

Addiction Medicine:

Closing the Gap

between Science and

Practice1

4

http://www.casacolumbia.org/addiction-research/reports/addiction-medicine







Addiction

For information on screening,

diagnosis, treatment planning

& management

Overview of Addiction

Medicine for Primary Care2

(62 Slides)

Overview of Addiction

Medicine for Primary Care:

Supplement3 (30 Pages)

5

http://bit.ly/Mdi6fo

http://bit.ly/Mdi6fo

http://bit.ly/1eQNfRS




Stabilization

• Withdrawal in some cases can be life-

threatening

• Medical management for

stabilization/detoxification may be required

• Details for these topics can be found on Pages

88-92 of the CASAColumbia® report Addiction

Medicine: Closing the Gap between Science and

Practice1

6

http://www.casacolumbia.org/sites/default/files/Addiction-medicine-closing-the-gap-between-science-and-practice_0.pdf#page=101





Addiction Treatment

• Treat addiction as a primary disease

• Address tobacco/nicotine, alcohol & other drugs

• Manage co-occurring disorders

7

dopamine

transporters


Combined Treatment

• Medications &

psychosocial therapies

• Can increase retention

in treatment

• Can decrease relapse

rates

8


Combined Treatment

• To achieve the best results medications should

be combined with psychosocial therapies

• Research studies illustrate the effectiveness of

various combinations of treatment4-6

• Details for psychosocial therapies can be found

on Pages 102-106 of the CASAColumbia® report

Addiction Medicine: Closing the Gap between

Science and Practice1

9





Specialist Referral

• Addiction medicine physicians

find a doctor near you

• Addiction psychiatrists

find a doctor near you

Addiction medicine physician: http://www.abam.net/find-a-doctor

Addiction psychiatrist: https://application.abpn.com/verifycert/verifyCert.asp?a=4

10

Consider for Complex Cases

http://www.abam.net/find-a-doctor

https://application.abpn.com/verifycert/verifyCert.asp?a=4









11

ADDICTION INVOLVING

TOBACCO/NICOTINE


FDA-Approved Meds

• varenicline (Chantix)

• bupropion (Zyban, Wellbutrin)

• nicotine replacement therapy

(e.g., patch, gum, lozenge,

inhaler, nasal spray)

• combinations

• combine with psychosocial therapies

Tobacco/Nicotine

12



varenicline (Chantix)

13

• 3X higher odds of

smoking cessation7

• Nicotinic acetylcholine

receptor partial

agonist8

• Superior to bupropion

& single-form nicotine

replacement therapy9



14

• Begin 1wk prior to

target quit date

• Starting dose 0.5mg

QD x 3dy

• Up to 1mg BID x 12wk

extension of 12wk



15

• Black Box Warning: neuropsychiatric events

• Common Side Effects: headache, insomnia,

nausea, abnormal dreams

• FDA Warning: increased risk of CV events in

patients with known CVD

• Meta-analyses show no increased risk of

neuropsychiatric events9 or cardiac events9-10


bupropion (Zyban, Wellbutrin)

16

• 2X higher odds of

smoking cessation11

• Inhibits

norepinephrine &

dopamine uptake12



17

• Begin 1wk prior to

target quit date

• Starting dose 150mg

QD x 3dy

• Up to 150mg BID

x 7-12wk extension

of 12wk



18

• Black Box Warning: neuropsychiatric events

• Contraindications: seizure disorder /

predisposition; abrupt cessation of alcohol /

sedatives; risky use / addiction involving alcohol

• Common Side Effects: insomnia, tachycardia,

weight loss, headache, lower seizure threshold

• Meta-analysis shows no increased risk of

neuropsychiatric events9


nicotine replacement (Nicoderm, Nicorette, Commit, Nicotrol)

19

• 1.5X to 2X higher odds of smoking cessation13

• Nicotine without exposure to other toxins



20

• Contraindications: severe angina, post-

myocardial infarction, pregnancy,

hypersensitivity

• Side Effects: minimal except nasal spray (local

irritation, cough, headache, dyspepsia)

• Combination long-acting (e.g., patch) & short-

acting (e.g., gum) better than single form13



21

Dosing for 1 cigarette 1mg of nicotine

• Patch (OTC): 7/14/21mg, q12-24hr, 8wk taper

• Gum (OTC): 2/4mg, q1-2hr, 3mo taper

• Lozenge (OTC): 2/4mg, q1-2hr, 3mo taper

• Inhaler (Rx): 6-16 cartridges, q24hr, 3-6mo taper

• Nasal Spray (Rx): 1-2 sprays, q1hr, 3-6mo taper



22

Delivery method characteristics

• Patch (OTC): only long-acting method

• Gum (OTC): “chew & park” technique crucial;

should not be used with acidic food or liquids

• Inhaler (Rx): beneficial for behavioral rituals

• Nasal Spray (Rx): fastest absorption, most side

effects


23

ADDICTION INVOLVING

ALCOHOL


FDA-Approved Meds

• acamprosate (Campral)

• disulfiram (Antabuse)

• naltrexone (ReVia, Depade,

Vivitrol)

• combine with psychosocial

therapies

Alcohol

24




acamprosate (Campral)

25

• Improves abstinence

& treatment

retention14

• May modulate

glutamate & GABA15


acamprosate (Campral)

26

• Begin once abstinent for >24hr if possible

• Dose at 666mg TID x 6mo

• Safe even with severe hepatic disease

• Contraindication: severe renal disease

• Common Side Effects: diarrhea, fatigue


disulfiram (Antabuse)

27

• Best efficacy with

routine use in

monitored systems

given high rates of

noncompliance16

• Aldehyde

dehydrogenase

inhibitor



28

• Causes diaphoresis,

headache, dyspnea,

hypotension, palpitations,

nausea, vomiting (when

using alcohol)

• Monitoring by spouse,

supervisor, etc. is highly

recommended



29

• Starting dose: 250-500mg QD x 1-2wk

• Maintenance dose: 125-500mg QD x 6mo

• Clinicians often start & maintain at 250mg QD

• Remains active 14 days after discontinuation

• Contraindications: severe myocardial occlusive

disease, psychosis, hypersensitivity

• Side Effects: hepatitis, psychosis


naltrexone (ReVia, Depade, Vivitrol)

30

• Decreases drinking by

83% over placebo17

• FDA-approved for

alcohol or opioids

• Mu opioid receptor

inhibitor

• Genetic factors affect

efficacy



31

• Only begin after abstinence from opioids >7dy

• Starting oral dose

25mg QD (Day 1), 50mg QD (Day 2)

• Maintenance oral dose 50mg QD x 6mo

• Depot dose 380mg IM q4wk: better compliance

• Trial of at least 3mo recommended



32

• Black Box Warning: hepatotoxicity

• Contraindications: acute hepatitis, liver failure,

prescribed opioids

• Side Effects: headache, GI distress, syncope,

LFT elevation

• Literature review suggests no increased risk for

causing or worsening hepatic disease18-19


33

ADDICTION INVOLVING

OPIOIDS


FDA-Approved Meds Opioids

34

• buprenorphine/naloxone

(Subutex, Suboxone, Zubsolv)

• methadone (Methadose)

• naltrexone (ReVia, Depade,

Vivitrol)*

• combine with psychosocial

therapies * details for naltrexone included on previous slides for addiction involving alcohol




buprenorphine/naloxone (Subutex, Suboxone, Zubsolv)

35

• Reduced use & better treatment retention20

• Partial opioid agonist + opioid antagonist

• Exercise caution in quantities prescribed per visit

due to potential for misuse

• Special training required in order to prescribe

• See details under section “For Physicians” at

buprenorphine.samhsa.gov

http://buprenorphine.samhsa.gov/


buprenorphine/naloxone (Subutex, Suboxone, Zubsolv)

36

• Starting dose

8mg QD (Day 1)

16mg QD (Day 2-3)

• Maintenance dose 12-16mg QD

• Contraindication: hypersensitivity

• Side Effects: respiratory

depression, headache, pain,

insomnia, GI symptoms


methadone (Methadose)

37

• Reduced use & better

treatment retention21

• Long-acting opioid

agonist

• Distributed only by

licensed facilities



38

• Starting dose 20-40mg QD

• Maintenance dose 80-120mg QD

• Dose may be less depending on baseline opioid

use

• Must follow licensed facility protocol, e.g., EKGs



39

• Contraindications: respiratory depression,

severe asthma, ileus, hypersensitivity

• Side Effects: QT prolongation, respiratory

depression


40

ADDICTION INVOLVING

OTHER DRUGS


FDA-Approved Meds Other Drugs

41

• Currently no FDA-approved

medications for addiction

involving other drugs

• Research & development

ongoing for marijuana,

cocaine, others

• Combine with psychosocial

therapies




42

FURTHER CONSIDERATIONS


For Prescription Drugs

Always consider risks of

addiction if prescribing

• Opioids

• Benzodiazepines

• Stimulants

• Other addictive

prescription drugs

43


For Adolescent Patients

• Only buprenorphine/naloxone

is FDA-approved for 16 years

& older

• All other medications are

FDA-approved for 18 years &

older

• Adolescent treatment should

focus more on psychosocial

therapies

44




For Elderly Patients

• Monitor for drug-drug interactions

• For renal insufficiency adjust dosing of

varenicline, bupropion, acamprosate,

methadone

• For hepatic insufficiency adjust dosing of

bupropion, buprenorphine/naloxone,

methadone, naltrexone (contraindication if

severe)

45


References

1. CASAColumbia. Addiction medicine: closing the gap between science and practice. 2012 Jun.


2. CASAColumbia. Addiction medicine: primary care clinical guide. 2013 Aug. http://www.casacolumbia.org/health-care-

providers/guide

3. CASAColumbia. Addiction medicine: primary care clinical guide supplement. 2013 Aug. http://www.casacolumbia.org/health-care-

providers/guide-supplement

4. Amato L, et al. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane

Database Syst Rev. 2011 Sep 7;(9):CD005031.

5. Anton RF, et al. Naltrexone combined with either cognitive behavioral or motivational enhancement therapy for alcohol dependence.

J Clin Psychopharmacol. 2005 Aug;25(4):349-57.

6. Feeney GF, et al. Cognitive behavioural therapy combined with the relapse-prevention medication acamprosate: are short-term

treatment outcomes for alcohol dependence improved? Aust N Z J Psychiatry. 2002 Oct;36(5):622-8.

7. Fiore MC, et al. Clinical practice guideline. Treating tobacco use and dependence: 2008 update. U.S. Department of Health and

Human Services, 2008 May.

8. U.S. Food and Drug Administration. Highlights of prescribing information for Chantix (varenicline). 2013 Feb.

http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021928s030lbl.pdf

9. Cahill K, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database

Syst Rev. 2013 May 31;5:CD009329.

10. Prochaska JJ, et al. Risk of cardiovascular serious adverse events associated with varenicline use for tobacco cessation: systematic

review and meta-analysis. BMJ 2012; 344:e2856.

46







http://www.casacolumbia.org/health-care-providers/guide






http://www.casacolumbia.org/health-care-providers/guide-supplement












References

11. Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD000031.

12. U.S. Food and Drug Administration. Prescribing information: Zyban (bupropion hydrochloride). 2012 Jan.


13. Stead LF, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012 Nov 14;11:CD000146.

14. Rösner S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004332.

15. U.S. Food and Drug Administration. Highlights of prescribing information for Campral (acamprosate calcium). 2012 Jan.


16. Laaksonen E, et al. A randomized, multicentre, open-label, comparative trial of disulfiram, naltrexone and acamprosate in the

treatment of alcohol dependence. Alcohol Alcohol. 2008 Jan-Feb;43(1):53-61.

17. Rösner S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD001867.

18. Brewer C, et al. Naltrexone: report of lack of hepatotoxicity in acute viral hepatitis, with a review of the literature. Addict Biol. 2004

Mar;9(1):81-7.

19. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. Naltrexone: LiverTox Clinical and

Research Information on Drug-Induced Liver Injury. http://livertox.nih.gov/Naltrexone.htm

20. Mattick RP, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane

Database Syst Rev. 2008 Apr 16;(2):CD002207.

21. Mattick RP, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane

Database Syst Rev. 2009 Jul 8;(3):CD002209.

47





http://livertox.nih.gov/Naltrexone.htm

http://livertox.nih.gov/Naltrexone.htm


Acknowledgements

• Margot Cohen contributed much of the research

and writing for these materials.

• The following subject-matter experts served as

external reviewers for these materials: Kevin

Kunz, M.D., M.P.H., Frances Levin, M.D.,

Charles O’Brien, M.D., Ph.D.

• Funding was provided by The Joseph A.

Califano, Jr. Institute for Applied Policy.

48

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Changes Everything

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OVERVIEW OF MEDICATIONS TO TREAT ADDICTION IN …...20 • Contraindications: severe angina, post-myocardial infarction, pregnancy, hypersensitivity • Side Effects: minimal except