Substance abusers are vulnerable to the same medical and psychiatric disorders as non substance abusers and they deserve prompt, appropriate, and effective medical treatment when they are afflicted by other illnesses. But, justified apprehension of primary care clinicians about prescribing psychoactive medications to this population often interferes with appropriate treatment of those at risk for substance use disorder. The apprehension consists of some of the following concerns:
· Initiation of iatrogenic (treatment caused) prescription drug addiction in those at risk or those with a previous history of substance use disorder
· Potential manipulation to obtain abusable medications and subsequent diversion of those medications for non-medical use
· Precipitating relapse in a recovering addict/alcoholic
· To be too cautious about prescribing medications may result in under-prescribing of needed medication
· Over-prescribing in response to an addicts pain or emotional hypersensitivities can result in excessive side-effects and even lethal overdose
· Fear that greater scrutiny of prescribing psychoactive medications in addicts leads to greater potential for legal, regulatory, licensing or other sanctions
When treating patients with a current or past history of addiction, medical providers often find themselves in a position analogous to Odysseus in Homers Odyssey, a Scylla and Charybdis situation of being between to equally perilous situations. Under-prescribing psychoactive medication to a substance use disorder patient has equally detrimental consequences as over-prescribing to this population. A predicament made even worse by the current upsurge of prescription drug abuse in the United States.1
To address this dilemma, an increasing number of practitioners have observed that some psychoactive medications are much less likely to be abused, diverted, result in dependency, or lead to relapse when prescribed to those with a past history of heavy drug addiction. 2, 3 Most of these medications have been approved by the U.S. Food and Drug Administration (FDA) to treat medical or psychiatric conditions other than what they are being used to treat in a substance abuser. Although the medications are not being used for what they approved to treat, medical practitioners are finding them to be effective and acceptable for the conditions they are being prescribed for in the chemically dependent population. The prescribing of medication for a condition other than what they are FDA approved to treat is known as off-label medical use of that medication. This is a fairly common and established practice in medicine. A good example of this is the user of neuroleptic (antipsychotic) and antidepressant medications to treat pain, anxiety, insomnia, ADHD and other conditions in patients who also suffer from substance abuser disorder. Clinical experience, pre-clinical, and animal research have demonstrated most if not all neuroleptic and antidepressant drugs to be devoid of dependence producing behavior. Thus, they are appropriate alternatives to narcotic analgesics, benzodiazepine sedatives or analeptic stimulants in the treatment of anxiety, depression, pain, insomnia or ADHD conditions in a patient who also suffers from a major substance dependence disorder.
Specific antidepressant, neuroleptic, antihistamine and other medications with low abuse potential that are currently used to treat medical indications usually treated by controlled substances are presented in the following table: Pharmacologic Alternatives to Controlled Drugs in Patients with Addictions. The table contains only the more common alternative medications and many others are being realized as clinicians become more aware of the need to effectively medicate those with potential for substance abuse disorder without activating that potential.
Pharmacologic Alternatives to Controlled Drugs in Patients with Addictions
Anxiety disorders-
Antidepressants (most, e.g. Zoloft, Paxil Lexapro, Celexa, Elavil)
Buspirone (Buspar)
Anticonvulsants: (e.g. Depakote, Depakene, Neurontin)
Selected antihypertensives (beta blockers, e.g. Inderal, Trasicor)
Atypical neuroleptics: (e.g. Zyprexa, Seroquel, Risperdal)
Insomnia-
Sedating Antidepressants Antihistamines
amoxapine (e.g. Ascendin) diphenhyramine (e.g. Benadryl)
doxepin (e.g. Sinequan) Chlor-Trimeton
Elavil Unison
nortriptyline (e.g. Pamelor)
Remeron Miscellaneous
Serzone hydroxyzine (e.g. Vistaril)
Tofranil promethazine (e.g. Phenergan)
trazodone (e.g. Desyrel) Rozerem
Attention-deficit disorder-
Cymbalta Tofranil
Catapres Wellbutrin
Effexor Zoloft
Luvox
Norpramin
Paxil
Strattera
Pain–
Nonsteroidal anti-inflammatory drugs (e.g. ibuprofen, Aleve, Clinoril)
Acetaminophen
Antidepressants (e.g. Cymbalta, Effexor)
Anticonvulsants (e.g. Topamax, Neurontin, Tegretol)
Steroids (e.g. Prednisone, Decadron, hydrocortisone)
Muscle relaxants (e.g. Flexeril, Robaxin, Zanaflex, Baclofen, Skelaxin)
Topical Anesthetic Creams
A crucial caveat needs to be emphasized about these proposed alternatives to controlled substances for patients with substance use disorders. Rarely are medications rigorously assessed for their potential to cause abuse or dependency. The FDA Investigational New Drug (IND) development process does require that medications be looked at for their potential to cause abuse or dependence but no standards exists for this evaluation. It is more common to observe abuse of drugs after they are brought to market than to get a meaningful understanding of their abuse liability during their pre-market development. If diversion and abuse is found to be significant after their release, they are then classified as Controlled Substances by the Drug Enforcement Administration (DEA) and placed in one of 5 categories: Schedules I to V with Schedule I being the most addictive and Schedule V being the least. Thus, some of the medications proposed to be good alternatives to controlled substances at the current time may be shown to possess abuse potential in the future. When this occurs, they should be removed from any list of medications recommended to be appropriate for use in patients at risk for addiction. Also, many non-controlled substances were not listed because of increasing reports they are now being diverted for abuse purposes. Examples of such medications are sleep aids like Ambien and Lunesta, muscle relaxants like Soma, and even non-prescription cough medications that contain dextromethorphan (DM or DXM). Interestingly, Lyrica is classified as a Schedule V Controlled Substance even though it hasnt yet been associated with great diversion or abuse. The FDA approved Lyrica to treat seizures, certain types of nerve pain, and symptoms of fibromyalgia. The acceptance to place it into Schedule V Controlled Substance occurred during its IND development. To assess Lyricas potential for abuse, Pfizer Pharmaceutical gave it to current drug abusers and asked them to describe its effects. The test subjects reported getting a high from Lyrica similar to that they obtained from taking Valium. Lyrica was then marketed as a Schedule V Controlled Substance even though there is little current evidence of it being diverted and abused. If Lyrica becomes abused at Schedule V or even at greater Schedule IV or III levels, then other similar anti-seizure medications like Neurontin and Topamax should also be scrutinized for their abuse potential especially when they are prescribed to patients with potential for substance abuse disorders.
All medications possess side effects and toxic profiles that require close evaluation when they are prescribed. Medications that work extremely well for most patients may be totally inappropriate for use in some patients. Further, some medications are better tolerated and cause fewer side effects than others in different individuals. These issues may limit the use of alternatives to controlled substances in those at risk for addiction. In recognition of this dilemma pharmaceutical companies have recently begun development of potentially diversion resistant medications in the hope of producing effective psychoactive medications that can be used in all patients including those with a elevated potential for substance use disorders.4
References:
1. SAMHSA 2007, National Survey on Drug Use and Health, (2006); ONDCP 2007, Teens and Prescription Drugs: An Analysis of Recent Trends on the Emerging Drug Threat
2. Johnson, B, Bursztajn, HJ, Paul, R, Coletsos, I (2007), Reducing the risk of addiction to prescribed medications. Psych. Times, 24(4), <http://www.psychiatrictimes.com/display/article/10168/54276 accessed 10/18/08>
3. Longo, LP, Parran, T, Johnson, B, Kinsey, W (2000), Addiction: Part II. Identification and management of the drug-seeking patient. Am Fam Physician, 61:2401-2408
4. American Pharmacists Association (2008). Pharmacotherapy for pain management: new treatment approaches. Continuing Education Monograph for Pharmacists, pp. 1-8, September 2008
Darryl S. Inaba, PharmD., CADC III