Randall D. Ordovich Clarkson, MD
August 21, 2022
Whether or not one should resort to prescription drugs in treating drug addiction is an ongoing debate in the world of behavioral medicine. The more puritanical arguments against pharmacotherapy regard such remedies as a “crutch,” replacing one form of dependence for another (see Alcoholics and Narcotics Anonymous). Unfortunately, this is a common motif amongst many mis-informed patients and practitioners alike (Baxter, 2014). On the other hand, one may argue that psychiatric medications should be considered akin to taking, for example, metformin for patients with type II diabetes mellitus (DM-II) or beta-blockers for patients with hypertension. Chemical dependence seen in substance use disorders (SUDs) can be just as physiological and psychological as other disease processes in medicine.
POTENTIAL BENEFITS OF PSYCHOPHARMACOTHERAPY
Similar to DM-II and hypertension, SUDs have been shown to involve genetic components as well as lifestyle factors. Hence, the argument to avoid prescription drugs in treating SUDs is fundamentally flawed and should be dispensed with, as psychopharmacotherapy can be useful either as monotherapy or adjunct therapy combined with other treatment modalities. An example of this would be the use of cognitive behavioral therapy (CBT) for smoking cessation in combination with bupropion, an antidepressant drug that simultaneously reduces cravings for nicotine (Brown et al., 2007; Evins et al., 2001).
Another important consideration is that SUDs are often accompanied by underlying psychiatric comorbidities that must be addressed through either psychotherapy, pharmacotherapy, or both. For instance, mood-stabilizers such as lamotrigdine can be useful when treating patients with bipolar I or II, both of which have disproportionately high incidence of SUDs (Goldstein & Bukstein, 2009). Another example may involve patients suffering from major depressive disorder (MDD) presenting with SUDs as a way to self-medicate.
In the treatment process, the underlying condition—i.e. depression—should be addressed pharmacologically, and the most common drugs used to treat MDD include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs). It is important to note as a side digression that a recent landmark study pointed out the inconsistencies in the serotonin-depression model stating that, “The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations” (Moncrieff et al., 2022). Because of that, novel treatment modalities including the use of psychedelics may be considered, including psilocybin and lysergic acid diethylamide for nicotine cessation as well as Ibogaine for the treatment of alcoholism (Glick & Maisovenneuve, 1998; Johnson et al., 2017). Fundamentally, despite the seeming inadequacies of SSRI type medications, certain therapeutics should be considered when approaching psychiatric conditions including SUD. Whatever decision a practitioner makes, they must consider both potential risks verses benefits.
WEIGHTING BENEFITS VS. RISKS
Psychiatric medications, as is often the case for other commonly used prescribed drugs, can carry adverse side-effects, including dependence, withdrawal, and potential for fatal overdose. The two most likely culprits in the realm of psychopharmacology are benzodiazepines and opioids. The former drug category consist of anxiolytic medications including Xanax (alprazolam), Valium (diazepam), Klonopin (clonazepam), and Ativan (lorazepam), to name a few. These drugs are commonly used in the treatment of conditions including generalized anxiety disorder (GAD) by inducing gamma-aminobutyric acid (GABA) receptors, increasing postsynaptic membrane conduction of chloride ions resulting in a sedative effect (Olsen, 1982). Despite the positive benefits of benzodiazepines, the FDA now require manufacturers to carry a black box warning describing the drug’s “risks of abuse, misuse, addiction, physical dependence and withdrawal reactions” (FDA, 2020).
Similarly, opioids such as methadone and Suboxone (buprenorphine and naloxone) are commonly used to treat the more dangerous forms of opioid addiction, which include intravenous (IV) heroin use as well as the use of fentanyl and other highly potent synthetic opioids that increase the risk of overdose and death. For instance, methadone maintenance treatment (MMT) has been shown to reduce the risk of HIV transmission, illicit opiate use, and property-related criminal behavior (Marsch, 1998). If used recreationally, methadone can confer similar risk of overdose and death as heroin and other illicit opioids. However, studies dating back to the mid 1960s have demonstrated that, when administered through highly-regulated treatment facilities, MMT can be instrumental in reducing the mortality of opioid-addicted patients (Bell, 2000).
CONCLUSION
Regardless of what treatment modality a therapist might choose, it is crucial to educate the patient about both benefits and potential risks of treatment. Furthermore, psychotherapists must work within a multidisciplinary team when considering pharmacotherapy. Thus, it is important to consult with psychiatrists and primary care providers to discuss the prescription’s risks, benefits, and potential contraindications (i.e. negative drug-drug reactions). At the end of the day, the goal for any behavioral health practitioner should be to reduce morbidity and mortality, regardless of whether the approach involves good drugs to combat the bad drugs.
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