New prescriptions are making it easier to kick old drug addiction habits and stay clean.
By Colette Bouchez
Reviewed By Charlotte Grayson
Shortly after radio talk-show host Rush Limbaugh publicly admitted addiction to prescription painkillers, he made a beeline for treatment. But coming to the decision to get that care -- much like for the more than 20 million Americans addicted to a wide variety of substances -- took a lot longer.
Indeed, experts say most people with substance abuse problems put off or even avoid treatment, not only because of the stigma attached to drug treatment programs, but also because many believe quitting drugs or alcohol will be nearly as difficult as living with the addiction. And for a long time, that was at least partially true.
"It's not like you could just go to your local doctor's office and get a prescription to help you get off drugs. You had to go to a drug clinic, and for many there was lots of embarrassment and sometimes certain difficulties associated with the treatment itself," says Gopal K. Upadhya, MD, a psychiatrist and medical director of New York's Areba Casriel Institute, the nation's oldest private drug and alcohol treatment center.
Now, however, much about the treatment of addiction has changed. Not only has the entire issue of substance abuse been reclassified from a social condition to a medical one -- thus removing a lot of the stigma -- but new medications are also making it possible to actually get a prescription for addiction right from your primary care doctor.
Among the drugs most frequently prescribed is Suboxone, which is used to treat addiction to painkillers like OxyContin (what hooked Rush Limbaugh) as well as heroin, and last year doctors wrote some 80,000 prescriptions.
"This medication is one of the most exciting things to happen in the world of drug treatment, not only because it works so well, but because you don't have to go to a drug treatment center or clinic to get it -- any psychiatrist or even a regular family doctor can prescribe it, and that alone helps to bring in a lot of people who might not ordinarily go for treatment," Upadhya tells WebMD.
While all addictive substances affect slightly different areas of the brain, the one thing they share in common is stimulation of the reward centers, the areas of the brain that release the pleasure hormones that make us feel good.
In the past, treatment was limited to those drugs that stimulated these same pleasure centers. But those drugs also produced a similar high. In the case of heroin addiction, the treatment drug methadone was often widely criticized because of its similarity to the substance being abused and its potential for abuse as well as dangerous overdosing."It was like substituting one addiction for another," says Upadhya. Suboxone, however, works in an entirely different way. By competing with heroin or opiate painkillers for the same receptors deep within the brain, Upadhya says it's able to knock out the withdrawal symptoms without "producing the high."
In addition, he says, because the drug has a built-in "ceiling effect" -- meaning that increasing the dosage will not enhance the satiation effects -- it becomes virtually impossible for addicts to abuse. And that, he says, makes it safer to prescribe without risk of overdose.
While Suboxone is fast proving successful -- one clinic boasts an 88% success rate after six months of treatment compared with just 50% for methadone -- not everyone has equal success. For some addicts the effects are simply not strong enough to cut the craving, while for others, side effects including headache, withdrawal syndrome, pain, nausea, and sweating can make treatment difficult. Still, experts say for most who try it, it offers the promise of treatment success with far fewer problems.
Addiction Treatment: Treating Alcoholism the New Way
Some experts believe that one of the factors responsible for the success of Suboxone lies not only in the power of the primary drug, but also in a second compound contained in this drug -- a medication known as naloxone. A powerful anti-addiction drug in its own right, naloxone, sold under the brand name Narcan, has also become a mainstay in the modern treatment of alcohol addiction. In fact, it's one of just two medications approved by the FDA for this purpose.
"When used in alcohol addiction, naloxone reduces cravings and diminishes the length of time alcohol is used while increasing the length of time an abstinent person might remain abstinent, " says Marc Galanter, MD, director of the division of alcohol and substance abuse at NYU Medical Center/Bellevue in New York.
Now joining naloxone in the fight is the drug Campral, approved by the FDA in August 2004. Galanter says it works much the same way as naloxone to stimulate the reward centers of the brain -- in this instance, by elevating levels of a brain chemical known as GABA. This, he says, reduces the need for alcohol without activating the numbing effects patients normally get from drinking.
"Research has shown that if you give [Campral] and naloxone together you can get an even better and more enhanced effect with somewhat better outcomes," says Galanter. Though not specifically approved for the use of alcohol addiction, Galanter adds that at least two other medications are being used effectively -- the epilepsy drug Topamax and the muscle relaxant Baclofen. Both are also undergoing testing as treatments for addiction to cocaine, heroin, and other opiates as well.
The Cutting Edge: The Addiction Vaccine
Experts say one reason almost any kind of drug addiction maintains such a strong hold on its victim has to do with not only the direct effects on the body, but also the somewhat indelible impression these substances make on our brain.
More specifically, imaging tests show that when exposure to drugs occurs with any kind of consistency, certain environmental and emotional cues associated with drug use become encoded in our psyche -- so much so that for some folks undergoing addiction treatment, even limited exposure to those original cues can activate a craving that causes a relapse. This, say experts, is particularly true of cocaine addiction, where the risk of falling off the treatment wagon can be quite high.
One way around the problem -- an "addiction vaccine" -- is a new way of helping to "cushion" the fall and keep relapses from overtaking treatment successes.
"The idea here is that if you've been vaccinated and you relapse, the effects of the cocaine are blunted, and that shifts the probabilities that you will relapse further, so you should be able to get your life back in order more quickly," says Margaret Haney, PhD, associate professor of clinical neuroscience at Columbia University and a researcher on the cocaine vaccine at New York State Psychiatric Institute.
Haney says the vaccine works by blocking the effects of cocaine not in the brain, but in the blood, beginning almost as soon as the patient takes the first "hit."
"It's a brand new treatment approach to drug abuse: The vaccine binds to the cocaine itself before it has a chance to cross the blood-brain barrier, and this prevents, or at least dramatically decreases, it's pleasurable effects," Haney tells WebMD.
Though an addict determined to get high can overcome the protection of the vaccine, Haney says within two to three months after treatment starts, there are enough antibodies in the blood to prevent at least three times the normal dose of cocaine from getting to the brain. So even if a craving is triggered, using cocaine will have little or no effect.
"It's still in the very early stages, and it will mostly likely be the most helpful when used in conjunction with other drug treatments, but it is our hope that it will prevent serious relapses from occurring in those who are motivated to overcome their addiction," says Haney.
Other vaccines under development include one for nicotine addiction, which researchers say is the furthest along, as well as others for heroin and other opiates.
Surgery for Addiction
When it comes to even more dramatic cutting-edge treatments, some doctors are turning to what we have already learned from two totally unrelated problems: Parkinson's disease and epilepsy. One treatment proving effective in both these conditions is a surgical intervention known as "electrical deep brain stimulation," and some experts believe it may work in drug addiction as well.
"For people who are sufficiently affected by their [addiction], deep brain stimulation it might be totally appropriate -- as appropriate as it is for Parkinson's or epilepsy," says Michael Kaplitt, MD, director of stereotactal and functional neurosurgery at Columbia Presbyterian Medical Center.
In this treatment, doctors implant a tiny electrode deep within the brain. Attached wires run under the skin to a small device located in the chest, not unlike a cardiac pacemaker. Using a hand-held unit similar to a remote control, patients can turn the electric current to their brain on and off, and in some instances, even regulate its strength.
In Parkinson's, Kaplitt says deep brain stimulation is being used to help control muscle tremors. In epilepsy, the treatment helps offset the occurrence of seizures. In drug addiction, he theorizes it may be useful in either stimulating the same area of the brain as the addictive substance -- thereby eliminating the need for the drug -- or by simply short-circuiting the cravings when they do occur.
"The anatomic pathways of drug addiction are similar to the Parkinson's pathways. Anatomically the areas affected are extremely close ... and thus far, animal studies suggest if you put electrodes into these same areas you can simulate or block drug addiction depending on how you stimulate," says Kaplitt.
While he stresses there are no human trials using deep brain stimulation under way for drug addiction, there are some in progress for depression and obsessive compulsive disorder. As such, Kaplitt believes the potential is also there for electronically wiping away drug addiction, and he hopes to start a clinical trial in the near future.
"Given that we have an even better understanding of the [changes in the brain that occur in] people with drug addictions as compared to depression, it seems perfectly reasonable to consider that we might be able to apply what we have learned from treating other diseases with deep brain stimulation to help people addicted to drugs. We can't predict or promise, but there's a definite possibility," says Kaplitt.
Published Oct. 18, 2004.
SOURCES: Gopal K. Upadhya, MD, medical director, Areba Casriel Institute, New York. Marc Galanter, MD, director, division of alcohol and substance abuse, NYU Medical Center/Bellevue Hospital, New York. Margaret Haney, PhD, associate professor of clinical neuroscience, Columbia University; researcher, New York Psychiatric Institute, New York. Michael Kaplitt, MD, director of stereotactal and functional neurosurgery, Columbia Presbyterian Medical Center, New York. The 2003 National Survey on Drug Use and Health, Department of Health and Human Services Substance Abuse and Mental Health Services Administration. Drug Abuse Report: Buprenorphine, National Institute on Drug Abuse.
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