The Continuing Debate: Increasing Use of Medications to Treat Substance Abuse

It appears that the use of medication to treat substance abuse continues to increase. On the surface this seems counterintuitive. Using drugs to treat drug abuse sounds like adding fuel to the fire for some. For others, justification is building. However, the debate and the use of drugs to treat drug abuse are not new. 

More than one hundred years ago it was suggested that morphine be used to treat alcoholism. Heroin was considered to be a cure for morphine addiction because it was a synthetic narcotic and thus though not to be addictive. Cocaine was once thought to be a cure for heroin addiction. In the 1950s, LSD was legally used as an adjunct to psychotherapy—it was believed that the use of LSD allowed the client to have better insight into their behaviors as well as retention of the therapeutic process. The rise of methadone maintenance programs in the 1970s was considered to be the answer to heroin addiction and since then the list of medications to treat addiction has grown.

Currently some of the most popular medications used in America to treat substance abuse are in the following categories.

Opioid Addiction

• Buprenorphine (Suboxone)
• Methadone (Dolophine, Methadose)
• Naltrexone (Vivitrol, ReVia, Depade)

Tobacco Addiction

• Bupropion (Zyban)
• Nicotine replacement (the patch, inhaler, nicotine gum)
• Varenicline (Chantix)

Alcohol Addiction

• Naltrexone (Vivitrol, ReVia, Depade)
• Acamprosate (Campral)
• Disulfiriam (Antabuse)

Cocaine Addiction

• Modafinil (research continues to show mixed results)

Although the above drugs are presently used, that does not necessarily indicate past approval. 

Overall there appears to be three schools of thought regarding the use of medications to treat substance abuse. These might be referred to as the purist argument, the medication treatment approach, and the social context approach.

The birth of the purist argument can be traced to the beginning of Alcoholics Anonymous (AA). It was thought that the use of any drugs would violate the beliefs and principals of Twelve Step programs. The slogan “Clean and Sober” meant drug and alcohol free in order to achieve and maintain sobriety. Throughout the years this has been the approach, even though Twelve Step groups advocate the importance of good health physically as well as emotionally and spiritually and this includes adhering to good medical practices. However, eventually the position became more rigid and simply stated that no medication should be used. This belief is based on the idea that in order to be truly sober you need to change your attitudes, thinking, and behaviors. It is difficult to do this when you are under the influence of other drugs. It is interesting that although the American Medical Association adopted the disease model of alcoholism more than sixty years ago the medical profession was little involved in addiction treatment for many years. Thus the use of medications was seldom discussed or advocated especially in the treatment of alcoholism that set the earlier stage for Twelve Step programs. As time passed the purist approach gained momentum and acceptance. Other arguments took hold as well. For example, were addicts just switching one drug for another? Was the use of other drugs really a crutch? It remained unquestioned until the reemergence of the medical profession in the treatment of alcohol and drug abuse. Drugs were, however, utilized to lessen the impact of abstinence syndrome or withdrawal such as in the case of delirium treatments.

The medical treatment approach can be divided into two areas. The first area is directly related to the addiction to drugs and the emphasis of the physiological and psychological effects of drugs on the addict. The use of medication to treat drug addiction is directed to altering the impact of the abused drug by blocking the effects of the drug to reduce craving or by counteracting the effects of the drug to reduce relapse episodes. This is especially true with opioid addiction.  

The second area concerns our increasing understanding of co-occurring disorders and the application of neuroscience. Historically addiction was thought to be a singular condition. It was not associated with underlying or accompanying psychological disorders. However, that is no longer the case. In fact, it is commonly believed that many addicts manifest anywhere between three to five psychological disorders that co-occur with their addiction. These are referred to as psychiatric disorders and the most prevalent are mood, anxiety, personality, and psychotic disorders. 

More specifically the most common co-occurring disorders with addiction today are the following:

• Alcoholism and antisocial personality disorder: According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), excessive alcohol drinkers are twenty one times more likely to manifest antisocial personality disorder (1991).
• Marijuana addiction and schizophrenia: Although not clear there appears to be a correlation between those with schizophrenia and marijuana abuse (Green, Drake, Brunette, & Noordsy, 2007).
• Cocaine addiction and anxiety disorders
• Opioid addiction and posttraumatic stress disorder (PTSD): Survivors of PTSD are often left with serious physical injuries as well as emotional damage. In recent years we have seen an increase in the use of painkillers for PTSD victims and the resulting addiction problems.
• Heroin addiction and depression: When the high of heroin addiction begins to fade and it is used more and more to avoid withdrawal it is not uncommon that depression develops in the heroin addict. 

Without a doubt co-occurring disorders need integrative treatment. The practice of using medications for psychiatric disorders is well established in American medicine. Whether addiction comes first or mental health disorders come first, we now know they often correlated. It should not be surprising then that medication-assisted treatment is now part of addiction treatment. 

There are many things in American culture to become addicted to. Although we represent only six percent of the world’s population, we have the greatest use of illegal drugs. The acceptance of process addictions is quickly occurring. At the same time we have the world’s most expensive health care system and the greatest concern for our health. Does any of this have to do with our culture? I think so. In the mid-1970s the noted psychiatrist, Thomas Szasz, stated that America is about to enter the age of therapy (1975). In other words, have we entered the age of treatment? 

Our use of drugs for medical reasons has increased. The motto of “Better Living through Chemistry” is alive and well in our culture. The pharmaceutical industry has grown to enormous proportions and they are pushing their products into every market they can find. They are not merely doing this on their own. We have created the demand for their drugs. We go to doctors to get something when we are ill and are disappointed if we don’t get a prescription. We expect it. We welcome these advances in hopes of better health, but we are also using these drugs for behavioral management. Sociologists write about the medicalization of deviance and how acts that once were considered deviant are now considered to be diseases and thus should be medically treated. This has been applied to nondeviant behaviors as well such as ADD and ADHD.

One has to wonder too if we are always looking for the quick fix or the one-step-approach to complex issues and problems. We have the highest standard of living in the world and at the same time the highest demand for mood altering drugs. Are we that unhappy or just that bored? Are our lives empty? In the late 1960s and early 1970s many Americans were shocked by the rise in drug abuse and addiction. However, today it is obvious that the shock value has been lost. It appears that we now accept drug abuse as an unfortunate by-product of our culture. 

This does not mean that we have given up the war on drugs. Although we have been officially fighting it since 1970 we accept that it has been a long war and one that will probably continue. We have had our successes and our setbacks. We are a culture, however, that doesn’t give up easily and this may be our greatest asset in this war on drugs.

I think that the debate over medication-assisted treatment will continue, but I do not think it will be as vigorous. We have reached a turning point. It is my opinion that we will continue to increase the use of medications for substance abuse treatment. Unwanted psychological symptoms can often undermine recovery and the control of these symptoms will not only assist in recovery, but also will help to reduce relapse. We don’t know what the next approach to treatment will be, but for now we are moving in the direction of medication-assisted treatment. 

Green, A. I., Drake, R. E., Brunette, M. F., & Noordsy, D. L. (2007). Schizophrenia and co-occurring substance abuse disorder. American Journal of Psychiatry, 164(3), 402–8.

National Institute on Alcohol Abuse and Alcoholism (NIAAA). (1991). Alcohol Alert, No. 14 PH 302. Retrieved from http://pubs.niaaa.nih.gov/publications/aa14.htm

Szasz, T. (1975). Ceremonial chemistry: The ritual persecution of drugs, addicts, and pushers. New York, NY: Anchor Press.