Substance Use Disorders 423
Naltrexone (reVia) is another medication used to treat alcohol abuse; after
detox, it can help maintain abstinence. Naltrexone indirectly reduces activ-
ity in the dopamine reward system, making drinking alcohol less rewarding
(O’Malley et al., 1992); it is the most widely used medication to treat alcohol-
ism in the United States, and it has minimal side effects. Another medication,
acamprosate, is more popular in Europe; acamprosate reduces cravings and
acts by affecting a different type of receptors (NMDA receptors; Johnson &
Ait-Daoud, 2000; Tomkins & Sellers, 2001). Researchers found that a combi-
nation of naltrexone and acamprosate is more effective in preventing relapse
among those in recovery from alcohol abuse than is either drug alone (Brady,
2005; Kiefer et al., 2003).
Finally, people with alcohol dependence who are undergoing detox may de-
velop seizures; to prevent seizures and decrease symptoms of DTs, patients may be
given benzodiazepines, along with the beta-blocker atenolol. However, a patient
with DTs should be hospitalized (Arana & Rosenbaum, 2000).
Narcotic Analgesics
Medications that are used to treat abuse of or dependence on narcotic analge-
sics are generally chemically similar to the drugs but that reduce or eliminate
the “high”; treatments with these medications seek harm reduction because the
medications are a safer substitute. For instance, patients with heroin dependence
may be given methadone, a synthetic opiate that binds to the same receptors
as heroin. For about 24 hours after a current or former heroin user has taken
methadone, taking heroin will not lead to a high because methadone prevents the
heroin molecules from binding to the receptors. Methadone also prevents her-
oin withdrawal symptoms and cravings (NIDA 2007c). Although patients on
methadone are likely to abstain from using heroin, they are still using a sub-
stance, and so methadone doesn’t promote complete abstinence, but rather
heroin abstinence.
Because methadone can produce a mild high and is effective for only 24 hours,
patients on methadone maintenance treatment generally must go to a clinic to re-
ceive a daily oral dose, a procedure that minimizes the sale of methadone on the
black market. Methadone blocks only the effects of heroin, so those taking it might
still use cocaine or alcohol to experience a high (El-Bassel et al., 1993). Another
medication, LAAM (levo-alpha-acetyl-methadol), blocks the effects of narcotic
analgesics for up to 72 hours (and so requires trips to a clinic only a few times a
week) and does not produce a high. However, LAAM can cause heart problems
and so is only prescribed for patients with a dependence on a narcotic analgesic for
whom other treatments have proven inadequate.
Methodone and LAAM are generally available only in drug treatment clinics. In
contrast, those seeking medication to treat abuse of or dependence on narcotic an-
algesics can receive a prescription for buprenorphine (Subutex) in a doctor’s offi ce.
Buprenorphine is also available in combination with naloxone (Suboxone). In either
preparation, buprenorphine has less potential for being abused than methadone be-
cause it does not produce a high. Treatment of opiate dependence with substitution
medications, such as methadone, is generally more successful than promoting absti-
nence (D’Ippoliti et al., 1998; Strain et al., 1999; United Nations International Drug
Control Programme, 1997).
Naltrexone is also used to treat alcohol dependence and often in combination
with buprenorphine, to treat opiate dependence (Amass et al., 2004). Naltrexone
is generally most effective for those who are highly motivated and willing to take
medication that blocks the reinforcing effects of alcohol or opioids (Tomkins &
Sellers, 2001).
Finally, the beta-blocker clonidine (Catapres) may help with withdrawal
symptoms (Arana & Rosenbaum, 2000). A summary of medications used to treat
substance abuse and dependence is found in Table 9.10.
P S
N