Addiction Medicine: Closing the Gap between Science and Practice

Research indicates that varenicline use,
compared with a placebo, can significantly
increase a patient’s chances of attaining
continual abstinence from smoking over six
months.^159 A large-scale analysis of several
randomized controlled trials found that the
medication was significantly more effective than
placebos or bupropion in relieving cravings and
in increasing the likelihood of achieving
continuous abstinence over a 12-month
period.^160

While nausea is the most commonly-reported
side effect, insomnia, headaches and nightmares
also are prevalent.^161 In February 2008--two
years after Chantix was approved--the FDA
released a public health advisory warning
patients that the medication has the potential to
aggravate psychiatric illnesses and in some cases
lead to the development of neuropsychiatric
symptoms, such as anxiety, tension, depression
or suicide attempts.^162 This advisory led to
modifications in the product labeling and the
medication guide advising medical professionals
to monitor all patients taking the medication for
neuropsychiatric symptoms.^163 More recently,
medical professionals were advised to monitor
use of the medication among patients with
cardiovascular disease since Chantix has been
linked to adverse cardiovascular effects in these
patients.^164

Modafinil, a stimulant medication (brand names
Provigil, Alertec and Modavigil), used to treat
narcolepsy and other sleep disorders, reduces the
stimulating effects of cocaine.^165 At the same
time, it may reduce cocaine cravings and
withdrawal symptoms.^166 In one study, patients*
with addiction involving cocaine who received
daily doses of modafinil for eight weeks
submitted nearly twice as many clean urine
samples than placebo patients during the course
of the study and were more than twice as likely
to achieve at least three weeks of prolonged
abstinence.^167 Another study found modafinil to
be effective in reducing cocaine use and cocaine
craving in patients with addiction involving

• Who met clinical diagnostic criteria for dependence

and who used at least $200 worth of cocaine during
the prior month.

cocaine† who took part in individual

psychosocial therapy.^168

Topiramate (brand name Topamax), an

anticonvulsant, has been validated by

randomized controlled trials to treat addiction

involving alcohol.^169 It is believed to work by

reducing the release of dopamine and thus the

rewarding effects of alcohol use and the urge to

drink.^170 It appears to reduce alcohol withdrawal

symptoms and can be used in patients who are

not yet abstinent from alcohol.^171 Topiramate

also is a promising pharmaceutical treatment for

addiction involving cocaine, but additional

research is needed to establish its efficacy.^172

Preliminary research suggests that the

anticonvulsant and mood-stabilizing medications

carbamazepine and valproate also may be

effective in treating addiction involving

alcohol.^173

Vaccines. Recent research in pharmacotherapy

for substance addiction has examined the use of

vaccines in the treatment process.^174 These

vaccines work by producing a sufficient quantity

of antibodies that bind to the substance and

prevent or significantly impede it from entering

the brain,‡ reducing the accumulation of the

substance in the brain and ultimately decreasing

its rewarding effects.^175 Much of the work on

vaccines for addiction is still in the preclinical

phase of development.^176

Vaccines for addiction involving nicotine§ are

farthest along in the development phase. They

are proving to be safe, with limited adverse side

effects and have shown promise for helping

smokers quit.^177 However, these vaccines still

are undergoing clinical trials to test for safety

and efficacy. While they may be helpful in

reducing the rewarding effects of nicotine in

those who already are addicted, they do not

† Who did not have co-occurring addiction involving

alcohol.

‡ Antibodies typically are comprised of larger

molecules than addictive substances, making them

less able to cross into the brain.

§ NicVax, Nic002 (also known as NicotineQB) and

TA-Nic are the vaccines currently under

investigation.