Long-Term Pharmacotherapy Strategies for Substance Use Disorder Management
New pharmacotherapies in combination with psychotherapy and counseling have proven effective in preventing relapse.
Ensuring long-term management of substance use disorders is extremely challenging as it involves significant change to an individual's personal interactions and social environment. As patients work to create a future without substances, their care providers must also anticipate relapses.1 Fortunately, numerous new pharmacotherapeutic tools in combination with psychotherapy and counseling have demonstrated efficacy for relapse prevention, as discussed by Roger Weiss, MD, professor of psychiatry at Harvard Medical School, in Boston, Massachusetts, in a presentation at the 2017 Psych Congress.
Long-acting depot medications and partial agonists are available for the management of opioid and alcohol abuse; pharmacogenetic approaches are also available for alcohol dependence. Disulfiram, naltrexone, and acamprosate are approved by the US Food and Drug Administration (FDA) for the prevention of alcohol relapse. While all three are effective, each are associated with advantages and disadvantages.
Naltrexone has been found to reduce alcohol cravings and enable individuals to return to abstinence sooner following relapse. It is also associated with few drug interactions and side effects. However, disadvantages include fluctuations in drug plasma levels and patient adherence to a daily treatment regimen.
Disulfiram is an effective alcohol use deterrent; however, it is associated with liver toxicity and potentially severe alcohol-induced reactions.
The efficacy of acamprosate to reduce an individual's desire to drink has been demonstrated in numerous non-US trials; however, recent US trials failing to demonstrate efficacy and 3-times-daily dosing are potential barriers to effective use.
Medications are also available for opioid use disorder: naloxone for the prevention of death from opioid overdose; and naltrexone, methadone, and buprenorphine for the prevention of opioid relapse. Certain aspects pertaining to each agent must be considered when choosing among these medications.
Methadone is only available through specialized opioid treatment programs; initiation of buprenorphine is usually easy while discontinuation can be difficult; and conversely, initiation of naltrexone can be difficult while discontinuation is often easy. Identifying the optimal treatment is best accomplished through a collaborative effort involving the clinician, patient, and patient's family.
In the setting of substance use disorder with comorbid psychiatric conditions, combination treatments are most effective, with the priority being treatment of the psychiatric disorder. Adverse effect profiles, patient and family history of response to medications, and adherence to treatment regimens are to be considered when choosing among medications.
“People had fewer psychiatric symptoms after taking any of these medications and that is because they are drinking way less, and that cures a lot of evils,” concluded Dr Weiss.
- Weiss RD. Advancing the long-term management of substance use disorders through medication-assisted treatment strategies. Presentation at: Psych Congress; September 16-19, 2017; New Orleans, LA.