Addiction Medication
• A tool to help you
maintain your
sobriety.
• Is it right for your tool
box?
YOUR BRAIN HAS BEEN CHANGED
Addiction is a chronic disease that changes both brain structure and
function. It begins with recognition of pleasure and ends with a drive
toward compulsive behavior.
⮚ The brain registers all pleasures in the same way, whether they are from a
psychoactive drug, a monetary reward, or a satisfying meal. Pleasure is felt
due to a release of the neurotransmitter dopamine in the nucleus accumbens.
⮚ All drugs of addiction, from nicotine to heroin, cause a particularly powerful
surge of dopamine. The likelihood that the use of a drug or participation in a
rewarding activity will lead to addiction is directly linked to
⮚ the speed with which it promotes dopamine release;
⮚ the intensity of that release;
⮚ the reliability of that release.
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In the current theory of addiction, dopamine interacts with another
neurotransmitter, glutamate, to take over the brain’s system of reward-related
learning. This system is important because it links activities needed for human
survival (such as eating and breathing) and motivation with pleasure and reward.
Addictive substances and behaviors stimulate the same circuit—and then overload
it.
► Repeated exposure to an addictive substance or behavior causes nerve cells in
the nucleus accumbens and the prefrontal cortex (the area of the brain involved in
planning and executing tasks) to communicate in a way that couples liking
something with wanting it, which then drives us to go after it. In other words, this
process motivates us to take action to seek out the source of pleasure.
Are there Medications that Can Help?
Detoxification Medications
Alcohol Detox Medications
Ativan (lorazepam), Valium (diazepam), and Librium (chlordiazepoxide)
⮚ frequently used to treat the symptoms most clients experience during the
alcohol withdrawal process. These medications can prevent the progression
from minor withdrawal symptoms to major ones like Delirium Tremens, and
can help control the shakiness, anxiety, and confusion associated with
alcohol withdrawal.
⮚ These medications are from the benzodiazepine class of drugs. Prolonged
use can result in addiction so they are only used for the first 3-7 days while
in detox and, where necessary, are tapered down during the last few days.
They are given on an as needed basis after an individualized assessment.
⮚ Common side effects: dizziness, drowsiness; weakness; slurred speech,
lack of balance or coordination; memory problems; or feeling unsteady.
Benzodiazepine Detox Medications
Phenobarbital
⮚ It is a barbiturate. It works by slowing activity in the brain. It can be used to
lessen withdrawal symptoms as well as for seizure precaution.
⮚ Phenobarbital tapers are used to detox from benzodiazepine due to the
danger of seizures. The length of the taper is determined on the quantity of
benzodiazepines taken.
⮚ Common side effects: drowsiness or dizziness; problems with memory or
concentration; excitement, irritability, aggression, confusion; loss of balance
or coordination; nausea, constipation; headache.
Opiate Detox Medication
Subutex/buprenorphine
⮚ It belongs to a class of drugs called mixed narcotic agonist-antagonists. In
other words, it is an opioid medication used to replace narcotics and help
prevent withdrawal symptoms from other opiates.
⮚ As an opiate, prolonged use can result in addiction. As such, a short taper
is prescribed for addiction withdrawal.
⮚ Buprenorphine works best when the first dose is started after signs of
narcotic withdrawal have begun.
⮚ Buprenorphine can cause withdrawal symptoms if started too soon after
your last narcotic use. Only take this medication orally. Injecting it is
dangerous and may cause severe withdrawal symptoms.
⮚ Common side effects: constipation, nausea, vomiting; headache; increased
sweating; sleep problems (insomnia); or pain anywhere in your body.
⮚ Subutex is used over Suboxone for pregnant women as the effect of
Suboxone on the unborn baby is unknown. Babies can be born dependent
if Subutex is used during pregnancy.
Suboxone/buprenorphine & naloxone
⮚ While buprenorphine is an opioid, naloxone is an opioid agonist. It blocks
the effects of opioid medication. Despite the inclusion of naloxone,
Suboxone can be addicting when used for a prolonged period. As such, a
short taper is prescribed for addiction withdrawal.
⮚ Suboxone typicially comes in either pill form or a dissolving film that you put
under your tongue. When using the film, for full dose absorbtion, do not eat
or drink for 20 minutes after placement under the tongue.
⮚ Buprenorphine works best when the first dose is started after signs of
narcotic withdrawal have begun.
⮚ Buprenorphine can cause withdrawal symptoms if started too soon after your
last narcotic use. Common side effects include: tongue pain, redness or
numbness inside your mouth; constipation, mild nausea, vomiting; headache
or other pain; sleep problems (insomnia); increased sweating; or swelling in
your arms or legs.
⮚ Buprenorphine and naloxone can pass into breast milk and may harm a
nursing baby. You should not breast-feed while using this medicine.
⮚ Only take this medication orally. Inhaling and injecting Suboxone has resulted
in death.
Opiate Maintenance
Medications
maintenance treatment can keep people in recovery
Methadone Maintenance
⮚ Methadone is the most widely used maintenance medication. It is a longacting opioid agonist.
⮚ It is a daily regiment and must be dispensed from federally licensed opioid
treatment programs.
⮚ It comes in pill or liquid form. If you are prescribed the liquid, it can be
harmful to your teeth so: drink it through a straw, chew gum, drink lots of fluid
and keep regular dental appointments.
⮚ Tolerance to one opioid, such as methadone, also blocks the effects of other
opioids by blocking the dopamine receptor. This is known as cross-tolerance.
Cross-tolerance develops between substances that act on the same types of
receptors in the brain. Tolerance to methadone develops slowly, so
maintenance can be indefinite.
⮚ Once the client is stabilized at the right dose, methadone will:
⮚ suppress opioid withdrawal symptoms
⮚ reduce the euphoric effects of other opioids, such as heroin.
⮚ not induce intoxication (e.g., sedation or euphoria)
⮚ reduce cravings for opioids
⮚ Common side effects: feeling anxious, nervous, or restless; sleep problems
(insomnia); feeling weak or drowsy; dry mouth, nausea, vomiting, diarrhea,
constipation, loss of appetite; or decreased sex drive, impotence, or
difficulty having an orgasm.
Levo-Alpha Acetyl Methadol
(LRAM) Maintenance
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LRAM is a synthetic opioid for opiate addiction maintenance; an alternative
to methadone.
It is administered only three times a week from approved medical facilities.
It can be highly addictive so take-home doses are prohibited under federal
regulations.
LRAM also works by creating a cross-tolerance to other opiates, blocking
the euphoric effects, and preventing withdrawal and controls drug cravings.
It is dangerous – potentially fatal- to mix LAAM with drugs like
benzodiazepines, alcohol, sleeping pills, antidepressants or other opiates.
Common side effects: body aches, flu-like symptoms, hot flashes,
abdominal pain, constipation, dry mouth, diarrhea, vomiting, nausea,
abnormal dreams, anxiety, depression, headaches, insomnia, rash,
sweating and blurred vision.
Suboxone Maintenance
⮚ Suboxone is an opioid/opioid agonist mixture. The goals of Suboxone
Maintenance are to alleviate withdrawal symptoms, suppress opiate effects and
cravings, and decrease the risk of opiate overdose from illicit drugs.
⮚ The effects are not as strong as methadone, but they last longer. Suboxone can
be taken once every 2 days and is typically in the form of a sublingual film.
⮚ Like Methadone and LRAM, Suboxone blocks the effects of other opioids by
blocking the dopamine receptor.
⮚ Suboxone can be dispensed in office-based settings by physicians in their
offices. The length of time patients continue to receive Suboxone varies and
may be indefinite.
⮚ Common side effects: headache, mild dizziness; numbness or tingling;
drowsiness, or sleep problems (insomnia); stomach pain, vomiting,
constipation; redness, pain, or numbness in your mouth; feeling drunk; or
trouble concentrating.
The Downside of Maintenance
Programs
⮚ Many experts believe that maintenance therapies helps to curb problems
associated with drug use including crime, disease, unemployment, child
neglect and homelessness.
⮚ However, Studies have shown that 60-70 percent of people put on
maintenance drugs quit on their own within a year because the drug still gives
them a feeling of intoxication and blunt emotions.
⮚ Many of the people who try to manage their own withdrawal from their
maintenance medication relapse to the original opiate because:
⮚ they are not receiving clinical support during withdrawal,
⮚ they aren’t given/don’t retain the tools to address anxiety and other issues
that may trigger cravings for the original opiate,
⮚ and they stop working the program.
Anti-Craving Medications
Naltrexone: Opiates and Alcohol
- Oral (Revia, Depade)
- Intramuscular Extended Release (Vivitrol)
⮚ You must be opiate free for 7 days prior to first dose as sudden opiate withdrawal
symptoms can occur within minutes after taking naltrexone if opioids were taken within 7
days.
⮚ Alcohol: It is not fully understood how Naltrexone works to reduce cravings. It seems to
work by decreasing the reinforcing effects of alcohol in neural pathways. It cannot prevent
you from getting severely intoxicated.
⮚ Opiates: Naltrexone works by monopolizing dopamine receptors in the brain that produce
feelings of pleasure. With fewer receptors firing, the ‘high’ is not experienced. 50%-70%
opiate users report a significant decrease in mental cravings and physical symptoms.
⮚ Warning: Vivitrol impairs your ability to feel intoxicated or high. If you continue to take
opiates in greater and greater amounts in an attempt to feel high, you risk overdose and
death. Do not use if you have liver disease.
Oral Naltrexone: Revia, Depade
⮚ Oral Naltrexone is daily. This can be a good option if:
⮚ You are a regimented medication taker
⮚ You live in a stable environment and have a stable life style
⮚ You do not have an authorized Dr. available to give you monthly injections
⮚ You don’t like needles, or needles are a trigger.
⮚ Advantages over Vivitrol:
⮚ Much less expensive if you pay out of pocket
⮚ Injection always leaves us open to possible site reaction or infection
⮚ Common Side Effects: Nausea, headache, dizziness, anxiety, tiredness, and
trouble sleeping. Serious side effects are rare but can include liver disease,
vomiting, abdominal cramps, diarrhea, joint/bone/muscle aches, mental/mood
changes (e.g., anxiety, confusion, extreme sleepiness, visual hallucinations),
runny nose.
IM Naltrexone: VivitrolV
⮚ Vivitrol is once every 28 days and is typically taken for 5-7 months. This
can be a good option if:
⮚ You are not regimented medication taker
⮚ You do not live in a stable environment or do not have a stable life
style
⮚ You have an authorized Dr. available to give you monthly injections
⮚ Advantages over oral Naltrexone:
⮚ You have coverage for 28 days so you can’t skip/miss a day
⮚ Steady more stable level of medication that lasts for weeks instead of
hours
⮚ Cost can be a barrier. Vivitrol costs $1200 to $1300 per injection.
However, once your deductible is met, it is typically a zero co-pay. For
those who haven’t met the deductible, Touchpoints, the company we work
with, puts forth a $500 co-pay payment toward your first injection. Most
people with a co-pay have met deductible after their second dose.
⮚ Ask yourself:
⮚ How much would another round of rehab cost me in
money, time, job and family?
⮚ How much was I spending on my addiction?
⮚ You will have an initial spike of medication on day 2-3 and then the
naltrexone stabilizes in your system for the month. We try to give the
dose 3 days prior to discharge so we can treat you should you have an
adverse reaction
⮚ You will be given a medical bracelet, dog tag or wallet card to notify
emergency personnel that you are on Vivitrol. The pain-relieving effects
of any narcotic pain medications will be blocked. This identification will
allow doctors to adjust medications to best help you.
⮚ Requesting Vivitrol: We need at least 10 days to enroll you in the
Vivitrol program and get your initial dose to our facility so request early.
For late decisions or follow-up injections, Touchpoints, the providing
company, coordinates an authorized physician near your destination.
⮚ Common Side Effects: Nausea, headache during the first few days after
administration and mild to moderate soreness at the injection site.
Serious side effects are rare, but include swelling of the liver; pain,
redness, swelling, hardness and tissue death at the injection site;
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pneumonia; and allergic reaction.
Topamax/topiramate
⮚ Available as a tablet or capsule, topiramate is
approved to treat certain types of seizures and
prevent migraine headaches.
⮚ Topiramate appears to correct a chemical imbalance in the brain
caused by chronic drinking including a decrease in "rewarding" effects in the
brain from continued consumption. It is not FDA-approved and so it is used
“off-label” to treat alcohol dependence
⮚ Most of the craving medications require people to stop from drinking before
starting the medication. Topamax/topiramate has been successful in treating
those who were still drinking heavily.
⮚ Side effects :memory and thinking problems, kidney stones so drink lots of
water, nearsightedness, glaucoma, acidosis (too much acid in the blood),
suicide and sedation. To minimize side effects, the dosage is increased slowly
over as long as eight weeks, which requires multiple doctor visits and means
results may not be achieved as quickly as they would with another medication.
⮚ Further studies are needed to determine its long-term safety, efficacy, and
potential role in the treatment of alcoholism.
Acamprosate (Campral): Alcohol
⮚ While the exact mechanism of action is unknown, it is thought to be an
dopamine agonist. It is typically taken in doses of 333mg or 666mg three times
per day for roughly 1 year.
⮚ A study published in TIME magazine stated that Acamprosate increased the
number of days sober by about 11%, and reduced the chance of their return to
drinking by 9% during a 3- to 12-month follow-up period.
⮚ You may take Acamprosate while in detox. It will not prevent withdrawal
symptoms. Acamprosate has not been shown to work in people who have not
stopped drinking alcohol.
⮚ Common Side Effects: diarrhea, gas, upset stomach, loss of appetite, dry
mouth, dizziness, itching, weakness, nausea, anxiety, difficulty falling asleep or
staying asleep, sweating. Serious Side Effects: burning, tingling, or numbness
in the hands, feet, arms, or legs, rash.
⮚ It is not metabolized by the liver so it can be used safely by people with liver
disease. It is primarily excreted by the kidneys and should not be used by
those with severe renal impairment.
Disulfiram(Antabuse): Alcohol
⮚ Disulfiram causes unpleasant effects when even small amounts of alcohol are
consumed: flushing of the face, headache, nausea, vomiting, chest pain,
weakness, blurred vision, mental confusion, sweating, choking, breathing
difficulty, and anxiety. These effects begin about 10 minutes after alcohol
enters the body and last for 1 hour or more. Avoid sauces, vinegars, and all
foods and beverages containing alcohol.
⮚ Disulfiram does not reduce cravings.
⮚ It is a daily medication. If you cannot swallow tablets, you can crush them and
mix the medication with water, coffee, tea, milk, soft drink, or fruit juice.
⮚ Common side effects: skin rash, Acne, mild headache, Drowsiness, Tiredness,
impotence, metallic taste or garlic-like taste in the mouth. Severe side effects:
excessive tiredness, weakness, lack of energy, loss of appetite, upset
stomach, vomiting, yellowness of the skin or eyes, dark urine.
Overdose Response
NALOXONE (Narcan):
ANTIDOTE TO OPIATE OVERDOSE
⮚ Naloxone is a medication approved by the Food and Drug Administration
(FDA) to prevent overdose by opioids such as heroin, morphine, and
oxycodone.
⮚ It comes in injectable vials, preloaded syringes, and nasal spray.
Drug Overdose Rates
⮚ Drug overdose is the leading cause of injury death in the US, causing more
deaths than motor vehicle accidents.
⮚ Overdose death rates have increased roughly 5 fold since 1990. The
increase in abuse of prescription painkillers is a key contributor to this
increase.
⮚ Opioid overdose is particularly amenable to intervention because risk factors
are well understood and there is a safe antidote – Naloxone.
Saving Lives
• How?
– Providing overdose prevention, recognition, and response education
• Who Needs It?
– Drug users, neighbors, friends, family, and service providers
• Why?
– Teaching intervention saves lives.
Overdose Factors:
* opiate strength,
* quantity taken,
* metabolism
What Puts People At Risk For
Overdose?
MIXING DRUGS
USING ALONE
VARIATION IN STRENGTH
AND CONTENT OF ‘STREET’
DRUGS (PURITY)
CHANGES IN
TOLERANCE
PHYSICAL HEALTH
Opioid Overdose
⮚ Rarely instantaneous
⮚ Can happen 1-3 hours after use
⮚ Body has ingested more than it can
handle
⮚ Opioids attack receptors that
control breathing
⮚ Oxygen can’t get to the brain
⮚ Heart stops
⮚ Unconscious, Coma, Death
⮚ Long-term Brain/Nerve/Physical
Damage
Naloxone Limitations
⮚ Naloxone injection may not reverse the effects of certain opiates such
as buprenorphine (Belbuca, Buprenex, Butrans) and pentazocine
(Talwin).
⮚ Naloxone only works on Opiates.
⮚ If you are given Naloxone and you are not overdosing on Opiates, it
won’t hurt you.
⮚ Overdoses with from high doses or people with a slow metabolism may
require additional naloxone doses.
⮚ If you are given additional doses, the additional 1 or 2 doses won’t
hurt you.
⮚ Because delayed release opioids, high doses, and slow metabolisms
can cause an overdose relapse, the person who overdosed should to the
hospital for observation.
⮚ If you are breathing well on your own, you should stay lying down on
your left side, the recovery position, until the ambulance arrives.
5 Essential Steps for First
Responders
Opioid Overdose Needs
Immediate Medical Attention
⮚ Check for signs of Overdose VS signs of Overmedication. Overmedication
can lead to Overdose. Overdose often results in death if not treated.
⮚ Signs of OVERDOSE: Extreme sleepiness, inability to awaken verbally
or upon sternal rub,breathing problems that can range from slow to
shallow breathing in a patient that cannot be awakened, fingernails or
lips turning blue/purple, extremely small “pinpoint” pupils, slow heartbeat
and/or low blood pressure.
⮚ Signs of OVERMEDICATION: unusual sleepiness, drowsiness, or
difficulty staying awake despite loud verbal stimulus or vigorous sternal
rub; mental confusion, slurred speech, intoxicated behavior; slow or
shallow breathing; “pinpoint” pupils; slow heartbeat, low blood pressure;
“death rattle”—an exhaled breath with a very distinct, labored sound
coming from the throat—emergency resuscitation will be necessary
immediately, as such a sound almost always is a sign that the individual
is near death.
Rescue
Breathing
⮚ Ventilatory support is an important intervention and may be life- saving on
its own. Rescue breathing can be very effective in supporting respiration
and should be done prior to administration of naloxone. Rescue breathing
for adults involves the following steps:
⮚ Be sure the person’s airway is clear (check that nothing inside the
person’s mouth or throat is blocking the airway).
⮚ Place one hand on the person’s chin, tilt the head back and pinch the
nose closed.
⮚ Place your mouth over the person’s mouth to make a seal and give 2
slow breaths.
⮚ The person’s chest should rise (but not the stomach).
⮚ Follow up with one breath every 5 seconds.
Using IM Naloxone
(naloxoneinfo.org)
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Verify signs of Overdose
Call 911
Give 2 rescue breaths
Administer one dose (1cc) intramuscularly into the upper arm, thigh or
buttock
Return to Rescue Breathing
Naloxone should work in about 1-3 minutes, if it doesn’t work in 3 minutes
or so give a 2nd dose
Naloxone wears off in 20 minutes-1 hour
The person can relapse back into the overdose, stay with the person or
transfer care to EMS.
Safe injection sites for
intramuscular naloxone:
⮚ The middle third
of the thigh.
⮚ Three fingers
down from the
top of the
shoulder.
Do’s and Don’ts in Responding to Opioid Overdose (SAMSHA)
SUMMARY
⮚ DO support the person’s breathing by administering oxygen or performing
rescue breathing.
⮚ DO administer naloxone.
⮚ DO put the person in the “recovery position” on the side, if he or she is
breathing independently.
⮚ DO stay with the person and keep him/her warm.
⮚ DON’T slap or try to forcefully stimulate the person—it will only cause further
injury. If you are unable to wake the person by shoutng, rubbing your knuckles
on the sternum (center of the chest or rib cage), or light pinching, he or she
may be unconscious.
⮚ DON’T put the person into a cold bath or shower. This increases the risk of
falling, drowning, or going into shock.
⮚ DON’T inject the person with any substance (saltwater, milk, “speed,” heroin,
etc.). The only safe and appropriate treatment is naloxone.
⮚ DON’T try to make the person vomit drugs that he or she may have swallowed.
Choking or inhaling vomit into the lungs can cause a fatal injury.
⮚ NOTE: All naloxone products have an expiration date, so it is important to
check the expiration date and obtain replacement naloxone as
needed.
Symptom Management
Anxiety
⮚ Vistaril (hydroxyzine): reduces activity in the central nervous system. It also
acts as an antihistamine that reduces the effects of natural chemical histamine
in the body. Vistaril is used as a sedative to treat anxiety and tension.
⮚ Propranolol (indural): is a beta blocker. It works by changing the response to
nerve impulses in the heart and other body parts, thus making the heart beat
more slowly, reducing blood pressure, and allowing the heart to pump more
efficiently. In low doses, Inderal is prescribed "off-label" for panic attacks.
⮚ Seroquel (quetiapine): is an antipsychotic drug approved to treat
schizophrenia and bipolar disorder. In low doses, Seroquel can be effective to
reduce anxiety.
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Pain
⮚ Ibuprofen: pain, fever and inflammation reducer. It relieves pain from various
conditions such headache, dental pain, muscle aches, or arthritis. It is also
used to reduce fever. Ibuprofen is a nonsteroidal anti-inflammatory drug
(NSAID). It works by blocking your body's production of certain natural
substances that causes inflammation. This effect helps to decrease swelling,
pain, or fever.
⮚ Acetaminophen: pain and fever reducer. It works by inhibiting the synthesis of
chemical messengers called prostaglandins, which help to transmit pain
signals and induce fever. Do not take more of this medication than is
recommended. An overdose of acetaminophen can damage your liver or
cause death.
⮚ Robaxin (methocarbamol): is used to treat muscle spasms/pain. It works by
helping to relax the muscles.
⮚ Neurontin (gabapentin): helps control seizures, reduce nerve pain, and ease
restless legs syndrome (RLS). It is of medications called anticonvulsants. It
prevent seizures by decreasing abnormal excitement in the brain and it
relieves pain by changing the way the body senses pain. It is not known
exactly how gabapentin works to treat RLS.
⮚ Baclofen: antispasmodic and muscle relaxant. It acts on the spinal cord
nerves and decreases the number and severity of muscle spasms. It also
relieves pain and improves muscle movement.
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Insomnia
⮚ Melatonin: supplement. It is a hormone made by the pineal gland in your brain,
a small gland in the brain. Melatonin helps control your sleep and wake cycles.
⮚ Trazodone: antidepressant. It affects several chemical messengers in the brain
including serotonin, dopamine, norepinephrine and acetylcholine. It’s mechanism
of action is unknown, but, as a side effect, it causes drowsiness.
⮚ Doxepin: tricyclic antidepressant. It works by affecting the balance of certain
neurotransmitters in the brain. It can help improve mood and feelings of wellbeing to help you sleep better.
⮚ Seroquel (quetiapine): antipsychotic. It is approved to treat schizophrenia and
bipolar disorder. It works by changing the actions of chemicals in the brain.
insomnia is relieved due to the sedative properties of this medication.
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Withdrawal
⮚ Clonidine: sympatholytics. It blocks the action of epinephrine and
norepinephrine, the two naturally occurring chemicals that trigger
sympathetic nervous system activity and the onset of fight-or-flight. This
leads to a reduced intensity in a range of common symptoms, easing
severity of withdrawal-related changes in the nervous system including:
anxiety, agitation, muscle aches, sweating, runny nose, and cramping.
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Questions….
Thoughts….
Feedback….
Withdrawal
• Robaxin or Baclofen 🡪 Muscle Spasm
• Vistaril or Inderal 🡪 Anxiety
• Clonidine 🡪 Chills, tactile skin
hallucinations, GI motility, Hypertension
• Phenergan 🡪 Observed vomiting
• Imodium 🡪 Diarrhea
• Ibuprofen 🡪 Pain
• Trazodone 🡪 Insomnia