Transcript Drugs For Treating Drug Addiction

Drugs For Treating Drug
Addiction
Barry Zevin MD
Tom Waddell Health Center
San Francisco Department of
Public Health Homeless Programs
Board Certified Internal Medicine
Board Certified Addiction Medicine
[email protected]
Disclosures And Disclaimer
•Barry Zevin accepts no payments, samples,
or gifts from any pharmaceutical companies
•The opinions expressed here are those of
the presenter
•All information regarding medications
expressed here should be checked out!
Drugs for Treating Drug Addiction?
•What’s the difference between a drug and a
medication anyway?
•If a medication could treat addiction, how
would we know it was working?
•Why have the results of this been
“disappointing” so far? Disappointing to who?
3 Flavors of Outcomes
•Traditional Abstinence Paradigm
•Neurobiology of Addiction Paradigm
•Harm Reduction Paradigm
What Would an Effective
Medication Look Like From a Harm
Reduction Point of View?
What is FDA Approved For Treating
Addiction?
•Tobacco: nicotine replacement, bupropion, verenicline
•Alcohol: chlordiazapoxide (specific regimen for withdrawal), diazapam
(specific regimen regimen for withdrawal), oxazapam (specific regimen
regimen for withdrawal), disulfiram, acamprosate, naltrexone
•Opioids – heroin: naltrexone, methadone only in NTP, buprenorphine
•Opioids – prescription opioids: naltrexone, methadone only in NTP,
buprenorphine
•Stimulants – methamphetamine: none
•Stimulants – cocaine: none
•Benzodiazepine, carisoprodol, GHB, Other sedative-hypnotics: none
•Marijuana: none
•Process Addictions – gambling, porno, shopping, etc.: none
FDA Approved For Indications
Other Than Addiction
•Tobacco: clonidine, nortryptaline
•Alcohol: benzodiazepines, topiramate, ondansetron, valproate,
other aeds, baclofen,
•Opioids – heroin: clonidine, other prescription opioids
•Opioids – prescription opioids: clonidine, other prescription
opioids
•Stimulants – methamphetamine: baclofen, other
psychostimulants, mirtazapine, bupropion, venlafaxine,
topiramate, other aeds
•Stimulants – cocaine: baclofen, naltrexone, topiramate, other
aeds
•Marijuana: gabapentin, pregabalin
•Process Addictions – gambling, porno, shopping, etc.:
naltrexone
Other Non FDA Approved
Substances Used to Treat Addiction
•Tobacco: Herbs (lobelia, St. Johns wort, oat
straw, valerian, ginseng)
•Alcohol: cannabis
•Opioids – heroin: heroin, ibogaine
•Opioids – prescription opioids: ibogaine
•Stimulants – methamphetamine: cannabis
•Stimulants – cocaine: cannabis
•Marijuana: ?
•Process Addictions – gambling, porno,
shopping, etc.: ?
Relevant Outcomes
•Safe / comfortable withdrawal
•Abstinence / relapse prevention
•Controlled use
•Reduced heavy use / Less using days / Less use overall
•Reduce harm related to mode of use, impurity of substance
•Prevent overdose
•Better mental health
•Better quality of life
•Reduce mortality
•Retention in treatment
•Reduce craving
•Anti-depressant
•Better cognition / Maintain cognitive function
•Reset tolerance
•Turn on or off effects of drug as needed
•Reduce criminal activity
What Works?
•Good evidence
–Scientific study
–Experience of practitioners and patients
•Relevant outcomes
•Reasonable safety – benefits outweigh adverse effects
•Acceptability to patients
•Acceptable cost for benefit
•Conversely what doesn’t work is defined by absence of
evidence, irrelevant outcomes, risk, and lack of
acceptability to potential patients, unavailable due to
high cost
What Works?
•BZD treatment of alcohol withdrawal
–Thiamine to prevent WKS
•Treatment of co-occurring mental health
disorders – esp. if treatment adds additional /
symptomatic benefits and has reasonable safety
and acceptability
–Depression treatment
–Psychosis treatment
–ADHD treatment
–Anxiety disorders
What Works?
•Naloxone to reverse opioid overdose
•Buprenorphine, methadone maintenance to
treat opioid dependence
•Nicotine replacement with gradual tapering to
treat tobacco dependence
–Nicotine patch plus short acting nicotine
•Nicotine replacement to reduce smoking even
in people not ready to quit
•Bupropion or nortryptaline to treat tobacco
dependence
•Varenicline to treat tobacco dependence
What’s Worth Trying?
Less Evidence / Less Relevant Outcomes /
Higher Risk / Less Acceptability
•Placebo for any indication
•Cannabis to treat various addictions
•Alcohol
–Baclofen, various aed’s to treat alcohol withdrawal
–Naltrexone for alcohol dependence
–Disulfiram for alcohol dependence when there is strong family or other
support for witnessed dosing
–Acamprosate for alcohol dependence
–Ondansetron for alcohol dependence esp in strong family history / early
onset drinkers
•Tobacco
–Nicotine replacement used indefinitely
–Verenicline for patients with underlying mental health disorders (in
patients who can be followed up closely)
What’s Worth Trying?
Less Evidence / Less Relevant Outcomes /
Higher Risk / Less Acceptability
•Opioids
–Clonidine for Opioid withdrawal (along with various other
symptomatic medications)
–Naltrexone for opioid dependence (in “highly motivated”?)
•Stimulants
–Baclofen for cocaine or methamphetamine dependence (esp
if chronic pain / muscle spasm)
–Psycho-stimulants for stimulant dependence in the absence
of ADHD
–Disulfiram for cocaine dependence esp in alcohol drinkers
who are willing to stop (not for actively drinking unable /
unwilling to stop)
• Process addictions
–Naltrexone
What Doesn’t Work?
•Anti-depressants for stimulant dependence when
depression is not present
•Dopamine agonists (eg bromocriptine, amantadine,
pergolide) or most aed’s for stimulant dependence
•Disulfiram for alcohol dependence in settings in which
daily dosing cannot be assured
•Naltrexone for opioid dependence in “less motivated”
patients
•SSRI’s in type II (early onset – strong family history)
alcoholism
–Worse outcomes than placebo
•Ultra-rapid opioid detox
Thank You to All My Colleagues
at Tom Waddell Health Center
and Our Many Partners
Thank You to My Patients Who I
Learn From Every Day