/publications/issue/2009/2009-03/2009-03-10055

Chronic Care Focus: The Recovering Addict

Author: Jeannette Y. Wick, RPh, MBA, FASCP

Addiction is not a problem of willpower or environment,1 and pharmacists who cling to these now outmoded beliefs risk alienating patients and missing the opportunity to help. Addiction stems from a complex set of processes in the brain's receptors that, over time, alters the brain's chemistry and how it responds. Up to one quarter of the patients you see in your practice may have current or past chemical dependency issues involving alcohol, drugs, or the combination of the 2.2,3 How can pharmacists best care for patients who have addictions and are in recovery (meaning that they have histories of addiction or abuse, but are not currently using)?

  1. Understand physical dependence, abuse, addiction, and tolerance. Clinicians' fears of causing addiction, physical dependence, and tolerance in their patients continue to influence prescribing practices negatively. Many drugs other than opioids and alcohol cause physical dependence and result in withdrawal symptoms when they are discontinued suddenly. Withdrawal symptoms are generally best managed by tapering the dose.
    Physical dependence crosses into abuse and addiction when an individual's substance or alcohol use becomes compulsive and continues despite harm and interference with activities of daily living, health, and relationships. Pharmacologic tolerance is the need for increasing doses to maintain drug effects.


  2. Appreciate recent research that demonstrates preexisting brain abnormalities contribute to the development of addiction. Individuals who become addicted had abnormalities even before being exposed to the substance of abuse.1 Addiction alters 2 major neurologic pathways. It often physically alters the mesolimbic dopamine reward pathway, causing uncontrolled cravings. It also can change the decision-making prefrontal cortex, which suppresses inappropriate reward response, accelerating "go" signals and impairing "stop" signals. Genetic defects in reward pathway neurotransmission and stress-related developmental brain abnormalities also may predispose some people to addiction.4


  3. Develop an attitude that allows patients to discuss their addiction without fear. Patients may or may not have noted a sobriety date, and if they have, noting the date in the record is good practice, as is recording what and how much the patient abused and the duration of the problem.5 Pharmacists should encourage successful abstinence but understand that relapse is not unusual. Should relapse occur and the patient seeks help, always encourage enrollment in support groups or appropriate programs.


  4. Know that 2 red flags may signal relapse: the patient's nonadherence, and dismissal of sound medical advice.5-7 Stress,4,8 cue-related reward pathway stimulation, or a single drug dose can start the addiction cycle all over again.4 Some ways pharmacists can encourage a return to abstinence are to remind patients who are actively drinking or using substances that maintaining sobriety will almost always improve other medical and psychological conditions, 6 and remind them of the benefits they enjoyed while abstinent. Escalating abuse quickly impairs functioning with often devastating consequences that are far worse than those stemming from the addict's previous addiction cycle.


  5. Identify support groups. Many if not most individuals who have addictions and become abstinent do so without using pharmacologic intervention. Traditionally, clinicians have referred people to 12-step programs like Alcoholics Anonymous and Narcotics Anonymous. Many patients have used 12-step programs successfully, but others may not embrace them. Today, many programs are available that use different approaches. Identify them and talk with group leaders about how they differ from or are similar to traditional programs. Also ask about their success rates.


  6. Exercise reasonable vigilance so the health care team does not do inadvertent harm. Injudicious use of prescription and OTC medications that may alter patients' vigilance and judgment can precipitate relapse.5,9 Review each new prescription using the guidelines in the Table. At every visit, ask the patient to list all current medications, including OTC drugs and herbal supplements.


  7. Watch for comorbid psychiatric illness, especially depression, anxiety, and posttraumatic stress disorder, and refer appropriately. Today, many psychiatrists earn addiction subspecialties and may be more helpful to patients with dual diagnosis than those who do not.5


  8. Watch for insomnia and pain and treat appropriately before they escalate. Many individuals report their problems with alcohol or substances started when they had trouble sleeping or were injured and treated for pain. In the abstinent patient, insomnia and pain represent treatment challenges, and nonpharmacologic interventions like relaxation techniques and lifestyle changes are essential. Regardless, clinicians will need to treat moderate-to-severe insomnia or pain; often, acetaminophen, nonsteroidal antiinflammatory agents, antidepressants, anticonvulsants, and other drugs usually considered adjunctive may help. If habitforming drugs must be used, the patient should see one prescriber and have prescriptions filled at one pharmacy.


  9. Know that chemically dependent individuals are more likely to smoke than others. This population often needs pharmacotherapy like bupropion or nicotine replacement and cognitive and behavior therapy to quit successfully. Using a program similar to the one that helped them kick alcohol or chemicals may improve their chances of success. If depression is a comorbidity, treating it first will improve the likelihood of smoking cessation.11


  10. Strive to individualize treatment just as you would for any other chronic condition. Traditionally, experts advised that addicts would seek treatment when they hit rock bottom. Today, the thinking is that intervening early and encouraging individuals to seek help is better—for the addict, the addict's loved ones, and society. Motivational interviewing can help pharmacists establish rapport, elicit change talk, and establish commitment from the patient:
    • Express empathy, so you understand the client's perspective.
    • Help patients see the difference between their real values and how they want their lives to be.
    • Roll with resistance means accepting that disinclination to give up an addiction or habit is natural rather than pathological.
    • Support self-efficacy means accepting when addicts choose to continue drinking or using, but helping them inch their inclination from not wanting the change to having the confidence to change; often this occurs in baby steps.12 This also is useful with patients who are reluctant to adhere to treatment or medication.13

Increasingly, patients choose to use pharmaceuticals to deal with their addictions. Pharmacists need a working knowledge of acamprosate, methadone, natrexone, and various anticonvulsants used in addictions.

Table

Medication Guidelines for the Recovering Addict

  • When patients present with conditions that are self-limiting, educate them that they have a choice regarding the use of medications to control symptoms.
  • Educate patients about nonpharmacologic interventions that alleviate symptoms.
  • Avoid sedating antihistamines, stimulating decongestants, and potentially moodaltering cough preparations.
  • Be aware of OTC and prescription drugs that are often abused (eg, amphetamines, benzodiazepines, dextromethorphan, carisoprodol, opioids, pseudoephedrine, and combination products that contain opioids or benzodiazepines), and suggest other products.
  • Recovering patients may hesitate or refuse to use any medication, fearing relapse. When medication is essential, good counseling and education can overcome this fear.

Adapted from references 5,10.


References

  1. Leshner A. What we know: drug abuse is a brain disease. In: Graham AW, Schultz TK, Wilford BB, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine; 1998:29-36.
  2. Meyers MJ. Substance abuse and the family physician: making the diagnosis. Fam Pract Recertif. 1999;21:53-76.
  3. Miller N, Wesson D, eds. Introduction. Integration of addiction medicine: education, treatment and research. J Psychoactive Drugs. 1997;29(3):231-232.
  4. Wise RA. Drug-activation of brain reward pathways. Drug Alcohol Depend. 1998;51(1-2):13-22.
  5. Jones EM, Knutson D, Haines D. Common problems in patients recovering from chemical dependency. Am Fam Physician. 2003;68(10):1971-1978.
  6. Schulz J, Parran T. Principles of identification and intervention. In: Graham AW, Schultz TK, Wilford BB, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine; 1998:260.
  7. Wartenberg AA. Management of common medical problems. In: Graham AW, Schultz TK, Wilford BB, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine; 1998:731-740.
  8. Sinha R. The role of stress in addiction relapse. Curr Psychiatry Rep. 2007;9(5):388-395.
  9. Beattie C, Umbricht-Schneider A, Mark L. Anesthesia and analgesia. In: Graham AW, Schultz TK, Wilford BB, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, 1998:886-887.
  10. Longo LP, Johnson B. Addiction: Part I. Benzodiazepines—side effects, abuse risk and alternatives. Am Fam Physician. 2000;61(7):2121-2128.
  11. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA. 2000;283(24):3244-3254.
  12. Shea SC. The "medication interest model": an integrative clinical interviewing approach for improving medication adherence—part 1: clinical applications. Prof Case Manag. 2008;13(6):305-315.
  13. Johnson L, Denham SA. Structuring successful interventions in employee health programs. AAOHN J. 2008;56(6):231-240.