Medicine to treat addiction?

Issue May/June 2017 By Dr. Jeff Fortgang

Q: I am a lawyer who works primarily within the financial services industry, and in my circle both drugs and alcohol are frequent accompaniments to business relationships. I guess you'd say my primary substance is alcohol, sometimes with side excursions into painkillers and cocaine, and things have gotten to the point where I've found it almost impossible to stop my increasing use. I have not been inclined toward participating in groups of any kind, but through some internet searching and asking around, I've learned that there are actually medicines used to treat alcohol problems, such as naltrexone and something called ibogaine. Do these work?

A: The first point to make here is that medications targeting alcohol/drug addiction are generally not meant to be stand-alone treatments. The measures that a person takes consistently over the long term are most highly correlated with lasting success, and frequency also makes a difference in most studies - this is one reason that so called "self-help" groups (which might be better termed mutual help groups) have become so central in addiction recovery, though certainly not everyone finds a way to make optimal use of them. But in my experience those who use any of these medications without also making longer-term use of therapeutic supports and lifestyle changes are likely to find that any improvement is not lasting.

Naltrexone (brand name Revia) is an opiate blocker that seems (at least for some) to reduce the urge to drink and also blocks the effects of painkillers or heroin. Acamprosate (Campral) is another prescription medication that, for some individuals, reduces alcohol cravings. The effects of both of these medications tends, from what I've seen, to be quite limited, e.g., people often say something like, "I think it may be helping, but I'm not sure." Two alternate means of prescribing Naltrexone claim better results; one, known as the "Sinclair Approach," uses a different dosing schedule and begins before a person has stopped drinking; the other, known as Vivitrol, is a monthly injected form of Naltrexone that is said to have a more continuous effect. A potential drawback to taking Naltrexone is that it will block the effect of a painkiller if you were to need one, for example, after unplanned surgery. (There are procedures for overriding the opioid blocking effect in an emergency - which must be carried out with careful medical supervision.)

Disulfiram (Antabuse) has been around for decades; its effect only kicks in if a person consumes alcohol, in which case s/he immediately becomes quite ill. So its real effect is cognitive - that is, the person realizes that instead of feeling in an way better upon drinking, the effect will be quite the opposite, so it is a tremendous deterrent. The main problem with Disulfiram is that many people stop taking it after the initial crisis passes; if you don't take it, it does not work. It is almost never recommended as a long-term treatment (or for those with heart or liver disease), but for some people it "buys time" while they develop ways to cope with life sober.

Ibogaine has also been around for many years. The product of an African plant, it is apparently part hallucinogen, part withdrawal-symptom reducer, and part antidepressant, and much touted by those who administer it, as a way to both detox and dramatically reduce craving for a period of time. Several studies have been done, mostly of a neurochemical nature, but despite the claims it remains illegal in the U.S. Even as an addiction specialist, I've rarely met anyone who has made the voyage and had this treatment. But even those who tout its wonders confirm that multifaceted ongoing help and lifestyle change are necessary in order to sustain good outcomes.

The good news is that it sounds as if you are ready to do something about your drinking and drugging. As a Massachusetts lawyer, you have access to a free and confidential clinical consultation at LCL, where we can more fully examine your options.

Dr. Jeff Fortgang is a licensed psychologist and licensed alcohol and drug counselor on staff at Lawyers Concerned for Lawyers of Massachusetts, where he and his colleagues provide confidential consultation to lawyers and law students, and offer presentations on subjects related to the lives of lawyers. Q&A questions are either actual letters/emails or paraphrased and disguised concerns expressed by individuals seeking LCL's assistance.

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