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Profile: Methadone Maintenance at Beth Israel

Treatment for addiction usually consists of behavioral-oriented strategies, such as psychotherapy, group counseling or family therapy, designed to help the addicted person change. Medications designed to suppress withdrawal symptoms and drug craving, or to block the "high" produced by the drug, may help by making abstinence easier. Although the general area of pharmacotherapy for drug addiction is still a brave new frontier, there are several well-tested methods, particularly for opiate and alcohol addiction/dependence, that are known to be effective. (But even those who support pharmacological treatment believe it must be done in conjunction with counseling and other therapy. Research shows that medication alone has success rates that are no greater than if a placebo was used.)

Medications for Opiate Addiction

Methadone, a substitute opiate medication that quells heroin withdrawal and craving, is the most successful proven treatment for heroin addiction in terms of reducing heroin use and improving social functioning. Hundreds of studies have shown that methadone patients have significantly reduced heroin use, particularly if they remain in treatment for long periods; that they commit fewer crimes; and that they are better-functioning.

Taken orally in pill or liquid form, methadone is a weak-acting synthetic opiate agonist (a medication that has pharmacological actions that are similar to the abused drug). While it imitates the action of opiates like heroin, thereby stabilizing the level of opiates in the bloodstream (and preventing withdrawal and craving), it doesn't produce a comparable euphoria or high.

So convinced are members of the medical and scientific establishment about the effectiveness of methadone that a National Institutes of Health expert panel in November 1997 urged the government to widen its availability so that more heroin addicts can benefit from it. Despite its proven effectiveness, however, the medication has become increasingly difficult to obtain. There are an estimated 600,000 heroin addicts in the U.S. But, because of limited access, only 115,000 of them receive methadone treatment. (See Policy: The Politics of Methadone.)


Teen Use of Heroin Growing

Finding a treatment for heroin is becoming even more imperative given that the face of the heroin user is getting younger. In 1995, 141,000 people tried heroin for the first time; 25 percent of those people were teenagers. Federal data show that there was a rise in heroin use among 8th, 10th, and 12th graders between 1991 and 1995. In 1994, nearly 60 percent of hospital emergency room admissions for heroin-related illnesses was among teenagers under age 18. In Boston, treatment agencies reported a surge in young heroin users in 1995 and early 1996. (The increased use of heroin may be due to the fact that it is now available in much purer forms, thus making it easier to "snort" rather than inject.)

Pills being dispensed

One of the most promising new treatments for heroin addiction is levo-alpha-acetyl methadol, or LAAM. Approved by the FDA in 1993, LAAM was the first new medication for heroin addiction approved in more than 20 years. Like methadone, LAAM blocks cravings for heroin and eliminates the high if heroin is taken. Its advantage is that it is longer-acting than methadone -- a big plus when patients must report to a clinic for each dose, as most methadone programs in this country currently require.

Another promising medication for opiate addiction is called buprenorphine, which does not appear to produce the same level of physical dependence as methadone. Discontinuing it is easier than stopping methadone treatment, because there are fewer withdrawal symptoms. It is not yet approved for treatment of opioid addiction and is still being studied by the National Institute on Drug Abuse.

Medications to Treat Cocaine Addiction

There are no effective pharmacological ways to treat cocaine addiction yet available. Most cocaine users are treated via psycho-social avenues, with an abstinence approach. But there are promising prospects being tested on animals. One is GBR 12909, a compound first tested in Europe as a potential antidepressant. In 1995, federal researchers studied the effects of GBR 12909 on cocaine use by monkeys and found that under the right conditions it could completely eliminate cocaine-seeking behavior for a couple of hours. One researcher who has examined the drug's effects on rats has said GBR 12909 might even reverse the process of cocaine addiction. The drug and some related compounds are being tested for possible use with humans.

Medications to Help Kick the Smoking Habit

Nicotine is one of the most addicting drugs of abuse, and one of the hardest to kick for good. According to Charles O'Brien, M.D., Ph.D., Director of the Addictions Research Center at the University of Pennsylvania Medical Center in Philadelphia, some 70 to 80 percent of people formally treated for nicotine dependence resume smoking by the end of a year. However, aids like the nicotine patch and gum have been developed to help some of those who want to quit. Most recently, an antidepressant called buproprion has also been shown to help people quit smoking. It's been on the market for this use since the summer of 1997 (under the brand name Zyban) and is the first FDA-approved non-nicotine product designed to help smokers quit. Researchers think it works by helping to normalize neurotransmitter levels in the brain.

Medications to Help Treat Alcoholism

Some recovering alcoholics take a medication called disulfiram, or Antabuse, which supports abstinence by making them very ill if they drink alcohol.

Another medication, called naltrexone, was developed to prevent relapse to opiates such as heroin by blocking the receptors for those drugs in the brain. But heroin addicts tend to resist taking it because it can cause dysphoria, or low mood, in those patients and does not eliminate craving for heroin. Naltrexone has also shown more promise, however, in the treatment of alcoholism, by reducing cravings for alcohol and blocking some of the drug's "high." It lowers relapse rates in recovering alcoholics and tends to stem minor relapses from becoming full-blown binges. University of Pennsylvania researcher A. Thomas McLellan, Ph.D., estimates that adding naltrexone to psychosocial treatments for alcoholism produces at least 30 percent more benefit than treatments without it.

Psychiatric Medications

Because many addicted people also suffer from co-existing psychiatric problems, such as depression or anxiety, that may interfere with recovery, treating those conditions can be very valuable in helping them maintain sobriety, experts say. Researchers are examining questions such as whether giving antidepressants such as Prozac increases sobriety rates. Some studies have been promising. One recovering alcoholic, who asked not to be named, comments, "I really wanted to quit drinking -- I checked myself in for three weeks of inpatient treatment and then joined AA -- but I couldn't manage a lasting sobriety until I got my chronic depression and attention-deficit disorder diagnosed and appropriately treated, which in my case was with medication. It's really hard to stay sober when you feel lousy all the time -- eventually you just want relief. I knew that if I drank again, I might die; but how much of a deterrent is that when you're suicidal anyway?"

-- Janet Firshein

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