The Space Between Stimulus and Response

Reflections on addictions counseling and creating change

Behavioral- and pharmaco-therapies combined create the best outcomes

4 Comments

I strongly support the use of pharmacotherapy in the treatment of addictions. In fact, SAMHSA documents “research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful (http://www.dpt.samhsa.gov/patients/mat.aspx) .”

To address the use of specific pharmacotherapies, there have been multiple research studies demonstrating methadone as more effective than non-ORT therapies for patient retention in treatment and for suppressing opioid use and demonstrating buprenorphine as significantly better than placebos for the suppression of opioid use and equally effective as methadone. Campral and naltrexone have also shown efficacy in promoting abstinence and in reducing heavy-drinking, respectively. These medications are not doing the work of recovery for clients, but they may give clients a slight edge, a pause if you will, during which they can think of consequences of old behaviors, use other craving- and thought-stopping techniques, and actually make new healthier lifestyle choices.

Neurologically speaking, it is understood that the frontal lobe system that inhibits risky behavior and weighs consequences to make decisions does not get to weigh in as it should when a person with addiction is triggered and driven by the pleasure pathway. Further, addiction depletes the brain of natural flowing feel good chemicals including dopamine, endorphins, serotonin and norepinephrine which can create a general lack of motivation and anhedonia in clients who are vulnerable and in early recovery. In my mind, carefully monitored pharmacotherapies help clients pursue treatment on a more level playing field, when the addicted brain would otherwise keep the decks stacked against them. Some will say that combating substance use with the use of other substances perpetuates the problem, but effective medications in the treatment of addiction typically allow individuals to function more normally, without pleasurable and problematic intoxication.

Of course, effective responsible use of pharmacotherapy should include a plan for eventual taper; it should include knowledge of evidence-based best practices; and it should take into consideration the risks of cross-tolerance/substitution and pharmacological interaction. For example, opioid replacement therapies (methadone or buprenorphine) can be contraindicated with the use of other sedating medications, like benzodiazepines, or in cases where a client continues to abuse depressants such as alcohol, because together they can increase the risk of respiratory depression and fatality.

I suppose pharmacotherapy for addiction might also encompass use of psychiatric medication for addressing comorbid issues such as hallucinations, delusions, depression, mania, anxiety,  inattention, impulsivity or hyperactivity. Our text (Capuzzi & Stauffer, 2012) points out that client with co-occurring psychiatric problems often have poorer treatment retention and poorer treatment outcomes. Appropriate psychiatric medication maintenance may improve treatment outcomes in these clients. It may also enable these clients to cope with other issues often present with co-morbidity, including inadequate social support, unstable relationships, insufficient housing and unemployment (as listed by Capuzzi & Stauffer, 2012). Again, treatment providers must ethically stay current on evidence-based practice. They must be mindful of which medications have greater potential for abuse. For instance, stimulant and sedative/hypnotic medications have fast-acting effects and high potential for abuse. Treatment providers must also be mindful of the fact that changes in the addicted brain may not represent symptoms of a client at baseline. Clinicians must be careful of making labeling and potentially stigmatizing psychiatric diagnoses while a client is in early recovery. Symptoms of withdrawal and post-acute withdrawal can often masquerade as symptoms of mood disorder. I believe clients should be assessed and then reassessed once well-established in recovery.

Capuzzi, D. & Stauffer, M.D. (2012). Foundations of addiction counseling (2nd ed.). Upper Saddle River, NJ: Pearson Education, Inc.

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4 thoughts on “Behavioral- and pharmaco-therapies combined create the best outcomes

  1. I also support the use of pharmacotherapies. Especially when combined with behavioral interventions and psychotherapy, these have proven highly successful. I like how you first mentioned SAMHSA & the research that has been done on the use of medication assisted treatment. These are the steps I took and ultimately am in favor of pharmacotherapies because it is an evidenced based practice. I really like how you pointed out that these medications are not doing the recovery work for clients. It is important for both client, counselor, and the general public to know that medication merely assists with recovery and there is no quick fix. I think some people may not be in favor of medication assisted treatment because they think the patient might immediately relapse, which is why it is so important that this method be combined with other forms of therapy. Great post!

    • Hi Chloe,

      Thanks for your comment! I like how you say people must “know that medication merely assists with recovery and there is no quick fix.” From what I’ve seen, clients who understand that medication is a supplement to treatment definitely make out better than those who believe the medications are their treatment. The former clients really take ownership of their recoveries and sometimes do well. Take care, Meg

  2. Great thoughts, Meg! I especially appreciated all of the research and information you included to support your opinion. The points you made are very clear, like how the medications affect a person neurologically. Every client is different, and just because they have the access to the medication that will be helpful to them does not mean that they will use it appropriately. Still, it should be attainable if pharmacotherapy is something that could assist someone in overcoming what they are struggling with. I completely agree with you that this method could be helpful to treating clients alongside therapy. Thanks for your insights!

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