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Sci-fi depictions of the future often portray a society that is free of all diseases because cure-all pills have been invented. These hopeful imaginations are a long way off from the current reality of medical research, but progress is being made to adapt prescription medications to uses hitherto unimagined. In the field of addiction treatment, researchers continue to work to develop medications that can improve a person’s chances of recovery. These medications are often discussed in addiction treatment literature as medication-assisted therapy (MAT), substitution therapy, or replacement therapy. People also sometimes refer to these as medications to stop or treat addiction.
When medications are used, they are always incorporated into a wider treatment curriculum. While medications don’t outright stop addiction, they can contribute to the success of a treatment plan. Medications are intended to be used in conjunction with the traditional approaches to drug abuse treatment, including individual therapy, group therapy, and group recovery meetings.
As the Substance Abuse and Mental Health Services Administration explains, medications that treat addiction are indicated for use in persons who are in recovery from opioid abuse. The opioid drug class encompasses heroin, methadone (even though this is a medication to treat addiction, it is also a potential drug of abuse), and prescription pain relievers.
Prescription opioids are typically branded drugs that include narcotic generics. Some examples of generic prescription pain relievers and their associated branded drugs are:
Opioids are unique on the drug landscape in that this category includes street-made drugs (heroin) and lawfully manufactured drugs (prescription analgesics). However, all opioids have one thing in common: They are highly correlated to addiction. Individuals who lawfully take prescription pain relievers as part of a medically managed pain management plan are not likely to become addicted (though they may form a dependence on the medication). However, individuals who use heroin, abuse methadone, or abuse prescription pain relievers face a significant risk of addiction. In order to understand that difference between lawful prescription pain reliever use and opioid abuse, it is helpful to consider the difference between physical dependence and addiction.
As the National Institute on Drug Abuse explains, opioids are addiction-forming but use may not necessarily lead to addiction. When individuals take opioids as part of a medically supervised treatment plan, they will become physically dependent on the opioid over time.
There are two main components of physical dependence: tolerance and withdrawal. Tolerance is most simply understood as the need to take more of a drug over time in order to experience the desired effects (i.e., to manage the pain). Withdrawal is triggered when a person who has a history of opioid use stops taking the drug altogether or significantly reduces the familiar amount. When a person is in withdrawal, a host of symptoms typically emerge, including cravings for the drug. Individuals who are on a medically managed treatment plan who, for any number of reasons, are going to discontinue opioid use will be tapered off the drug.
A person who abuses opioids can rapidly move from physical dependence to addiction. Being addicted to opioids involves the components of physical dependence, plus a psychological attachment to the drug. The psychological need for the drug underlies a host of behavioral symptoms that can signal that addiction has set in. Such behaviors can include failing to meet important obligations, spending a disproportionate amount of time and resources on getting and using drugs, getting into legal trouble, committing petty or grand crimes, or experiencing anxiety at the prospect of not having access to the drug.
The logic of medications that are used to treat addiction is that they can make the withdrawal process significantly more comfortable and stem cravings. A main goal these medications is to help the recovering person avoid a relapse during the withdrawal process and the maintenance phase of treatment inside and outside of a rehab program. The medications indicated for the treatment of opioid abuse include:
Each of these medications will be discussed further, but at this juncture, it is helpful to broadly discuss how opioids work in the brain. In turn, it is easier to understand how medications that treat addiction work at the neurological level. Although psychopharmacology is a highly technical and niche area of medicine, a few basics about the interaction of drugs and the brain can be illuminating.
When a person consumes an opioid, irrespective of the particular method of administration (e.g., chewing, snorting, swallowing, smoking, or intravenous injection), this narcotic will enter the bloodstream and make its way to the brain. Once in the brain, opioids attach to opioid receptors there. The typical result is that pain is blocked, the person’s breathing slows, and an overall calming effect takes place. If the opioid is potent enough, the person will experience psychoactive effects, such as euphoria, the pleasurable experience that makes initial and ongoing drug abuse desirable.
It is important to understand that opioid receptors in the brain were not designed for drugs but for neurotransmitters that naturally occur in the brain. The brain’s reward system exists to encourage survival. For instance, when a person eats, it is pleasurable because the brain wants to motivate the person to eat again and therefore live. Nature likely did not intend for the brain to interact with outside drugs, but the brain can be manipulated by them.
Prescription medications, heroin, and morphine mimic the neurotransmitters that naturally occur in the brain, which is why they are able to dock into the brain’s opioid receptors. But drugs have a much stronger impact on the brain’s opioid receptor sites than naturally occurring neurotransmitters (hence, rather than a natural mild feeling of pleasure, a person experiences an arresting rush of intense euphoria).
Heroin, morphine, opium, and prescription medications (if abused) cause the brain’s reward system to be flooded with dopamine, a pleasure-inducing neurotransmitter. With continued abuse, the ongoing overactivation of dopamine in the brain causes an overall imbalance that can, unfortunately, strengthen the likelihood of addiction setting in and being maintained. In short, drugs hijack the brain’s reward system and detrimentally change its operations.
Now that the basics of opioids in the brain have been outlined, a discussion of how medications that treat addiction can be better understood. There are three main categories that are referred to in the literature regarding medications to treat addiction: full opioid agonists, partial opioid agonists, and opioid antagonists.
Methadone is classified as a full opioid agonist, buprenorphine is a partial opioid agonist, and naltrexone is an opioid antagonist. These classifications reflect the different types of activity each of these medications has on opioid receptor sites.
As methadone is a full opioid agonist, it fully activates the opioid receptor site and is therefore capable of producing full euphoric effects. As a result, methadone can suppress withdrawal, stop other opioids from docking in the receptor site and having euphoric effects, and reduce cravings for opioids. However, in view of the potency of methadone, the key to methadone treatment is to provide just enough of this medication to stop opioid abuse without triggering methadone abuse.
Buprenorphine, being a partial opioid agonist, partially activates the opioid receptor site and is therefore capable of producing euphoric effects, but it is milder when compared to opioids. Subutex is a branded drug that includes buprenorphine as its only active ingredient. Suboxone is a buprenorphine product that also includes naloxone, an opioid antagonist. If a person takes Suboxone and then abuses an opioid, naloxone will induce withdrawal symptoms and hence create a disincentive to abuse opioids while on Suboxone. In this way, naloxone is considered an anti-abuse feature (methadone has no such feature). Both Subutex and Suboxone can block the effects of other opioids and
suppress withdrawal symptoms and opioid cravings. Even though buprenorphine has a milder side effect profile compared to opioids, it is susceptible to abuse. For this reason, buprenorphine therapy necessarily includes some level of medical oversight. Note that naloxone and naltrexone (discussed in the next section) are separate drugs.
As naltrexone is an antagonist, it is able to block opioids from docking onto the opioid receptor site, but it does not activate the site; hence, there are typically no psychoactive effects associated with naltrexone use. As naltrexone is not considered to be capable of inducing euphoria, its abuse profile is deemed minimal; however, a person on naltrexone therapy will usually experience withdrawal symptoms. For this reason, attending medical personnel will discuss the risk of relapse on naltrexone with a client in recovery.
Now that it is established how methadone works, it is useful to know how it fits into the recovery treatment framework. Most often, the recovery process begins with medical detox. After detox is complete and the recovering person is safely stabilized on methadone, the next stage is methadone maintenance. Some individuals will choose to remain on methadone for months, years, or a lifetime, while others will use this treatment as a bridge to full abstinence.
During the detox process, those with a history of opioid abuse who elect methadone treatment will be inducted into maintenance therapy. The methadone dose a person receives will be based on a host of physiological factors and therefore varies by the individual’s specific needs.
In the context of methadone treatment, the term detox is not entirely accurate; while it is true that the recovering person is detoxed from the opioid of abuse (such as heroin), the person is transferred onto methadone, which is another drug. In this way, the recovering person cannot be said to be drug-free. However, there is a significant difference between a person on methadone therapy and a person who is abusing heroin or other opioids. Those who successfully follow their methadone treatment plan will be physically dependent on methadone without being addicted to it.
Methadone received approval from the U.S. Food and Drug Administration in 1947 and has been used in the field of addiction treatment for more than three decades. The following are some of the most well-documented pros and cons of methadone treatment:
Most broadly, anyone who has a history of abuse of opioids is a candidate for methadone. However, some individuals who meet this threshold criterion will not be ideally situated to receive this narcotic therapy for a host of different reasons. Such reasons include, but are not limited to, a pre-existing health condition that this drug would exacerbate, being on medications that would negatively interact with methadone, being pregnant, or having a severe allergic reaction to methadone.
As noted above, methadone maintenance requires a person to make daily, or near daily, visits to a methadone distribution clinic. Some people may be unable to do so due to disability, transportation limitations, or a general apathy toward treatment. A person who is not a candidate for methadone treatment may be a candidate for buprenorphine, buprenorphine/naloxone, naltrexone, or an abstinence-focused method that does not involve any drugs.
The U.S. Food and Drug Administration approved buprenorphine for clinical use in 2002, and this drug was considered a significant advancement in the field of addiction treatment science. One of the most touted aspects of buprenorphine is that it is more convenient than methadone maintenance. There is no need for a daily visit to a buprenorphine distribution clinic because buprenorphine is the first addiction treatment medication that can be prescribed in a host of medical settings, including a doctor’s office. The following branded medications are approved to include buprenorphine as an active ingredient:
When buprenorphine and buprenorphine products are used, they are involved in addiction recovery treatment in three phases: the induction phase, the stabilization phase, and the maintenance phase. The induction phase typically begins 12-24 hours after last use of an opioid. A qualified doctor or certified opiate treatment program (OTP) will determine the best buprenorphine medication to use. The treating medical personnel will determine appropriate dosing. If people have any opioids in their systems, the use of buprenorphine can precipitate intense withdrawal symptoms. For this reason, it is important that this medication first be taken under the supervision of a medical professional.
The stabilization phase is considered to begin after a person has considerably detoxed from the opioid of abuse and experiences few, if any, cravings or other side effects. At this stage, the attending medical personnel may continue to adjust the dosing to accurately track and meet the recovering person’s needs. Since buprenorphine is long-acting, after clients are stabilized, they may be able to take buprenorphine every other day rather than daily.
Once recovering people have demonstrated responsiveness to buprenorphine and have a sufficient amount of stabilization time under their belts, they are considered to be in the maintenance phase. The duration of the maintenance phase can be months, years, or a lifetime.
Some individuals may opt to undergo a supervised withdrawal from buprenorphine. Some recovering people may also opt to transition from buprenorphine to morphine maintenance (or vice versa). It appears that it may be easier and safer for persons to transition from buprenorphine to abstinence rather than from opioid abuse to abstinence. As stated earlier, a person who is on buprenorphine therapy is said to have detoxed off the opioid of abuse but is not drug-free because buprenorphine can be detected in a drug test.
Candidates for buprenorphine treatment must meet threshold criteria, including but not limited to:
As Suboxone is commonly used, it is helpful to consider the different pros and cons associated with this branded drug. As Health Research Funding discusses, a main criticism of Suboxone is one that can be leveled against all medications that target addiction, chiefly that abstinence is preferable to dependence on a new medication.
It is difficult for some researchers and clinicians to overcome the fact that Suboxone and other buprenorphine products can themselves be addiction-forming. In addition, Suboxone has side effects, including headache, nausea, dizziness, mood changes, and depression. There is also concern that people may consume alcohol while taking Suboxone, which can present numerous health hazards.
However, proponents of Suboxone and other buprenorphine products point to research and client feedback that support that Suboxone safely helps recovering individuals to safely detox from opioids and avoid relapse. Some recovering people feel that buprenorphine is instrumental to their recovery, and the abstinence approach may not be as effective for them.
Naltrexone, a generic drug, is the active ingredient in at least two branded medications: Vivitrol and ReVia. ReVia is a pill that is taken orally whereas Vivitrol is an injectable medication. A treating medical professional will discuss the pros and cons of each formulation with eligible clients. Studies have shown each medication can be effective in the treatment of alcohol abuse or opioid abuse. Hence, naltrexone is unique compared to methadone and buprenorphine in that it has specifically been indicated in the treatment of alcohol use disorders rather than opioid use disorders alone.
As previously noted, naltrexone and naltrexone products are opioid antagonists and have been shown to be effective in helping people maintain abstinence. Naltrexone and naltrexone products do not have psychoactive effects and have not been shown to be addiction-forming. They can reduce or eliminate withdrawal symptoms, including cravings. According to reports, the side effects associated with naltrexone are mild and short-lived, and it usually has no impact on a person’s psychological state.
Due to the formulation of ReVia and Vivitrol, it is imperative that those inducted into this medication have no alcohol or opioids in their bodies. This also means that people should not be experiencing any opioid withdrawal symptoms.
Pregnant women are advised not to take either drug. Naltrexone and naltrexone products are known to negatively interact with certain health conditions and medications. Both ReVia and Vivitrol must be initially administered by medical personnel, which helps to ensure safety in the induction phase.
Research has identified some of the benefits associated with use of Vivitrol. According to the Addiction Technology Transfer Center Network, when Vivitrol was compared to placebo studies, results showed positive results for those treated with Vivitrol.
Advocates of naltrexone and naltrexone products believe these drugs outweigh the potential drawbacks. But what are the cons associated with naltrexone? Again, some individuals interpret abstinence to be an entirely drug-free life; hence, they do not agree with use of medication treatments like naltrexone. In support of this contention, they point to the side effects of these medications, consequences that they believe undermine the recovering person’s overall wellness. Side effects associated with naltrexone include but are not limited to anxiety, dizziness, depressed mood, increased or decreased energy, headache, irritability, joint and muscle pain, and sleeplessness.
Individuals who are allergic to naltrexone or who cannot take it for any other reason can speak with attending medical personnel about other treatment options.
Recovery is an interactive process between the recovering person’s goals and the treatment staff’s clinical expertise. In order to ensure participation and comfort in the recovery process, a rehab program will necessarily factor in a recovering person’s reasonable goals, provided those goals do not compromise the effectiveness of treatment.
It is important to understand that the use of medications to stop addiction may be advisable but not necessarily mandatory. Such use may depend on the treatment center’s philosophy of recovery and established treatment curriculum. An effective recovery plan is one optimized to ensure a person achieves and maintains abstinence, and this often includes the option to use medications to address addiction.
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