Pubdate: Mon, 08 Aug 2005 Source: Wichita Eagle (KS) Copyright: 2005 The Wichita Eagle Contact: http://www.kansas.com/mld/kansas/news/editorial/4664538.htm Website: http://www.wichitaeagle.com/ Details: http://www.mapinc.org/media/680 Author: Deborah L. Shelton, St. Louis Post-Dispatch Bookmark: http://www.mapinc.org/heroin.htm (Heroin) Bookmark: http://www.mapinc.org/find?136 (Methadone) Bookmark: http://www.mapinc.org/rehab.htm (Treatment) PROMISING MEDICATIONS LEND HOPE TO ADDICTS SEEKING TREATMENT ST. LOUIS - At his lowest point, Steve Duffie was popping pills and shooting heroin up to 10 times a day. Then he started taking a drug to stop. Since February, he has been traveling three times a week to south St. Louis, where a staff person at Assisted Recovery Centers of America watches him swallow pills containing naltrexone. "I feel a lot better," said Duffie, 24, who has stayed drug free. "I feel better about myself and the life I'm living now." Naltrexone has been around for 20 years, but few people know about it. Experts say a major shift in thinking about how alcohol and drugs impact the brain is producing more and better medications to treat addiction to drugs and alcohol. "Based upon an accumulation of research findings, our ideas about what alcohol dependence is, when it starts and how to treat it are changing rapidly," Dr. Mark Willenbring of the National Institute on Alcohol Abuse and Alcoholism told a recent American Medical Association briefing. "New tools are becoming available, and treatment outcomes, while perhaps better than most people think, are likely to significantly improve in the next decade if we can get these treatments to the people who need them." Research into medications to treat addiction has taken off. Twelve years ago, the federal government was funding just a half-dozen clinical trials of drugs for alcoholism, and no pharmaceutical company was conducting research. Today, the government is financing studies of 51 drugs, and nine companies are doing clinical trials. Like antidepressant medication, some of the newer drugs are designed to repair chemical unbalances and abnormalities in the brain that occur as a result of chronic abuse, Willenbring said. Promising medications include brand new drugs and those already approved for other purposes. Among them: Topiramate - approved to treat epilepsy - for alcoholism and cocaine addiction. Baclofen - approved for muscle tightness, cramping and spasms - for alcoholism. Ondansetron - to treat nausea and vomiting - for alcoholism. Nalmefene - approved in 1994 for alcoholism - is being developed as a six-month implant for both alcoholism and opiate addiction. Federal health officials held a forum July 29 at St. Louis University, part of a four-city stop, to raise awareness among doctors and the public about one medication, buprenorphine. Marketed under the trade names Suboxone and Subutex, it went on the market in 2003 to treat heroin, prescription painkiller and other opiate addictions. Like naltrexone, it can be prescribed by private-practice physicians, so "hopefully it will allow addiction treatment to be incorporated into mainstream medical practice," said Nick Reuter, senior public-health advisor at the U.S. Substance Abuse and Mental Health Services Administration. Finding new medications for alcoholism has been challenging because different regions of the brain are involved. That complexity also "opens up many strategies for treatment," said Dr. Raye Litten, associate director of the division of clinical and recovery research at National Institute on Alcohol Abuse and Alcoholism. Naltrexone was approved by the FDA in 1984 to treat opiate addiction, and in 1994 to treat alcoholism. It also is being studied for use in combination with acamprosate, the latest anti-addiction drug to gain FDA clearance. Sold under the trade name Campral, acamprosate went on the market in January. An injectable form of naltrexone, Vivitrex, is currently undergoing review by the FDA as a monthly shot. Down the road, people might take two or three medications that act on specific parts of the brain, experts say. The drug combinations would work much like those designed for people with AIDS, cancer, diabetes, depression, heart disease and high blood pressure. "Just getting them out on the market would give patients a menu of medications to choose from," Litten said. "Like antidepressants, if one doesn't work, you could try another one." Researchers are learning that many alcoholics and drug addicts need ongoing or intermittent care much like people with other chronic conditions. "Treatment should not be a one-time thing," said Willenbring, a psychiatrist who directs the division of treatment and recovery research at the federal health agency. Treatment professionals caution that a commitment to abstinence is essential. "You can't put this into somebody's coffee everyday and expect them to be transformed," said Barbara Mason, a consultant to Forest Laboratories, Inc., the company that makes Campral. "It's another tool in the toolbox of recovery." Yet, for all the excitement about pharmaceutical treatments, naltrexone and acamprosate are largely going unused. Only about 5 percent of people dependent on alcohol have ever been prescribed medication, Willenbring said. Fewer than 3 percent of the nation's 1.1 million opiate addicts have tried naltrexone, even though it's been around for 20 years. The reasons vary - from low awareness of the medications to lack of drug coverage and a bias against taking a drug to beat an addiction. "Most people think addicts just need to learn how to change their behavior," said Dr. David Gastfriend, an associate professor of psychiatry at Harvard Medical School. "That's like fighting this disease with one hand tied behind your back." Naltrexone works by occupying the opiate receptors in the brain. As a result, the feel-good chemicals triggered by alcohol and opiate drugs are blocked, eliminating the high. The brain chemicals are endorphin, dopamine, serotonin and gamma-amino butyric acid, or GABA. The active ingredient of naltrexone is made in St. Louis by Tyco Healthcare/Mallinckrodt, the biggest U.S. manufacturer of the drug. Studies have found that people who are genetically predisposed to addiction have lower levels of endorphin in their brains but experience an excessive release of the chemicals when they drink or do drugs, well beyond what the average person experiences. Repeated heavy drinkers and drug users build up a tolerance and require more and more to get high. Eventually, alcohol or drugs are taken to relieve the unpleasant effects of not using, such as irritability, anxiety and craving. "You're drinking to feel normal," said Barbara Mason, co-director of the Pearson Center for Alcoholism and Addiction Research at the Scripps Research Institute in California. Since naltrexone blocks the release of endorphins, if an alcoholic drinks, speech might become slurred or walking might get wobbly, but there's no buzz. If the person relapses on the medication, he or she is more likely to stop after two or three drinks because the reward of feeling good has been taken away. After using naltrexone for several months, some alcoholics are able to abstain from alcohol forever. Some treatment professionals describe the drug as a "chemical chastity belt." Acute withdrawal from alcohol and drugs can last up to seven days. Alcoholics and addicts typically go through a protracted withdrawal that lasts up to 30 weeks, which can include overwhelming feelings of craving, said Percy Menzies, a pharmacist who is president of Assisted Recovery Centers of America. Naltrexone acts like a "helmet on the brain that protects you if you fall," Menzies said. About 22 million people abuse or are addicted to drugs, according to government statistics. That figure includes alcohol and prescription drugs. "We have a serious drug-abuse problem in this country, including with alcohol, even if we don't recognize it," said Dan Duncan, director of community services at the National Council on Alcoholism and Drug Abuse, St. Louis area. "We have a lot of stereotyping going on, people want to think it's an inner-city problem. That's not true. Go to west county. They're doing drugs and have the means and resources to buy whatever they want. It costs all of us and we're affected directly or indirectly by this problem." Alcoholism is a disease of behavior, spirit and the brain, Mason said. "There are therapies that deal with each aspect of the disease. AA is a spiritually-based fellowship. There are alcohol-specific types of counseling. But the brain has been largely ignored in recovery. Campral is the very first drug that addresses the underlying brain aspect of the disease and helps to restore that piece to normal." Naltrexone doesn't repair anything in the brain; it keeps people from getting high and eases withdrawal. Campral, or acamprosate, works differently. Alcohol overstimulates the glutamate system, causing it to react like a car that's idling too fast, Mason said. The abnormality can continue as long as a year after the last drink in some alcoholics. Acamprosate regulates the chemical activity in the glutamate region. Campral is shipped to pharmacies across the country from Forest Laboratories' national distribution center in St. Louis. Other drugs used to treat addiction are methadone and disulfiram. Methadone is an opiate given in small doses to prevent the effects of withdrawal from drugs such as heroin. The narcotic is designed to block the high and reduce craving. Disulfiram, which is sold under the trade name Antabuse, has been used to treat alcoholism since 1949. Drinking while on the drug makes a person violently ill with nausea, vomiting, heart palpitations and other symptoms. The aim of researchers is to design newer drugs that don't make people sick and are not habit-forming or mood-altering. The side-effects of naltrexone and acamprosate are generally mild, if any. They are not addictive and don't produce a high. The drugs usually are prescribed from three months to a year. Research on naltrexone, disulfiram and acamprosate is uncovering other benefits. It appears that disulfiram helps cocaine addicts. People with a family history of alcoholism appear to do better on naltrexone. And while acamprosate doesn't appear to have a gender effect, one study on the naltrexone monthly shot reported that it seemed to work better in men. Jim Selby keeps a bottle of naltrexone on the kitchen counter as an insurance policy. A leg injury led to his five-year prescription drug habit. "Before I knew it I was taking it all the time," said Selby, 47. "That's the way I was getting by. They had complete control over my life." He credits his turnaround to his mother, Patricia Selby, who worked many years for the Al-Anon Information Center in St. Louis. She directed him to Assisted Recovery Centers of America. He has been drug-free for two years. Menzies often keeps the pills of patients who haven't been abstinent as long as Selby at his clinic so he can monitor whether they are taking them. Patients are advised to attend frequent group therapy sessions and to phone regularly. "The more contact, the better the outcome," Menzies said. Dr. Robert Swift is a professor of psychiatry and human behavior at Brown University. "The medications that we have are effective but not as effective as we would like them to be," he said. "Not all people are helped and the cure rate is not 100 percent. These medications need to be used in the context of counseling and psychosocial treatment." Addiction impairs motivation, so getting people to take their pills every day can be a formidable task, said Gastfriend, who's vice president of medical affairs at Alkermes Inc., the company seeking approval of the monthly shot. Vivitrex could make it easier to stay on the medication. "By extending the action for 30 days, if they come in one day for medication, they don't have to be motivated to come in the other 29 days," Gastfriend said. Buprenorphine is used as a replacement drug for heroin, painkillers and other opiates. Subutex is the pure form. Suboxone is a combination tablet of buprenorphine and naloxone. Naloxone was added to prevent addicts from grinding and injecting the tablets to get high. The benefit of buprenorphine is that it may be easier to quit that street drugs or prescription medicines. In a phone interview, Dr. Clifford Bernstein, an addiction specialist, says he has seen an increase in the number of people who've become addicted to it. An informational booklet from the manufacturer warns that patients can become physically dependent. "Patients need to be educated that it's a replacement therapy which is half opiate in composition," Bernstein said. But at the St. Louis University forum, Theodore Cicero said research at Washington University in St. Louis suggests that buprenorphine is a safe alternative that has less potential for abuse than opiates. Cicero is vice chancellor for research at the university. Steve Duffie was prescribed Suboxone for two weeks. Then he was switched to naltrexone. His mother, Cathy Duffie, is convinced he would have died without the medications. "It's amazing what addiction can do to you," she said, glancing at the son she never gave up on. "It's a horrible life." - --- MAP posted-by: Beth