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)?
- 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.
- 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
- 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
- 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.
- 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.
- 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.
- 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
- 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.
- 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
- 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
- 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.
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
- 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
- Recovering patients may hesitate or
refuse to use any medication, fearing
relapse. When medication is essential,
good counseling and education can overcome
Adapted from references 5,10.
- 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.
- Meyers MJ. Substance abuse and the family physician: making the diagnosis. Fam Pract Recertif. 1999;21:53-76.
- Miller N, Wesson D, eds. Introduction. Integration of addiction medicine: education, treatment and research. J Psychoactive Drugs. 1997;29(3):231-232.
- Wise RA. Drug-activation of brain reward pathways. Drug Alcohol Depend. 1998;51(1-2):13-22.
- Jones EM, Knutson D, Haines D. Common problems in patients recovering from chemical dependency. Am Fam Physician. 2003;68(10):1971-1978.
- 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.
- 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.
- Sinha R. The role of stress in addiction relapse. Curr Psychiatry Rep. 2007;9(5):388-395.
- 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.
- Longo LP, Johnson B. Addiction: Part I. Benzodiazepines—side effects, abuse risk and alternatives. Am Fam Physician. 2000;61(7):2121-2128.
- 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.
- 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.
- Johnson L, Denham SA. Structuring successful interventions in employee health programs. AAOHN J. 2008;56(6):231-240.