Chronic Care Focus: The Recovering Addict

Addiction is not a problem ofwillpower or environment,¹ andpharmacists who cling to thesenow outmoded beliefs risk alienatingpatients and missing the opportunity tohelp. Addiction stems from a complexset of processes in the brain's receptorsthat, over time, alters the brain'schemistry and how it responds. Up toone quarter of the patients you see inyour practice may have current or pastchemical dependency issues involvingalcohol, drugs, or the combination ofthe 2.^2,3 How can pharmacists best carefor patients who have addictions andare in recovery (meaning that they havehistories of addiction or abuse, but arenot currently using)?

• Understand physical dependence,abuse, addiction, and tolerance.Clinicians' fears of causing addiction,physical dependence, and tolerancein their patients continue to influenceprescribing practices negatively. Manydrugs other than opioids and alcoholcause physical dependence and resultin withdrawal symptoms when theyare discontinued suddenly. Withdrawalsymptoms are generally best managedby tapering the dose.Physical dependence crosses intoabuse and addiction when an individual'ssubstance or alcohol use becomes compulsiveand continues despite harm andinterference with activities of daily living,health, and relationships. Pharmacologictolerance is the need for increasing dosesto maintain drug effects.
• Appreciate recent researchthat demonstrates preexisting brainabnormalities contribute to thedevelopment of addiction. Individualswho become addicted had abnormalitieseven before being exposed to thesubstance of abuse.¹ Addiction alters2 major neurologic pathways. It oftenphysically alters the mesolimbic dopaminereward pathway, causing uncontrolledcravings. It also can changethe decision-making prefrontal cortex,which suppresses inappropriate rewardresponse, accelerating "go" signals andimpairing "stop" signals. Genetic defectsin reward pathway neurotransmissionand stress-related developmental brainabnormalities also may predisposesome people to addiction.⁴
• Develop an attitude that allowspatients to discuss their addictionwithout fear. Patients may or may nothave noted a sobriety date, and if theyhave, noting the date in the record isgood practice, as is recording what andhow much the patient abused and theduration of the problem.⁵ Pharmacistsshould encourage successful abstinencebut understand that relapse is notunusual. Should relapse occur and thepatient seeks help, always encourageenrollment in support groups or appropriateprograms.
• Know that 2 red flags may signalrelapse: the patient's nonadherence,and dismissal of sound medicaladvice.^5-7 Stress,^4,8 cue-related rewardpathway stimulation, or a single drugdose can start the addiction cycle allover again.⁴ Some ways pharmacists canencourage a return to abstinence are toremind patients who are actively drinkingor using substances that maintainingsobriety will almost always improveother medical and psychological conditions,6 and remind them of the benefitsthey enjoyed while abstinent. Escalatingabuse quickly impairs functioning withoften devastating consequences that arefar worse than those stemming from theaddict's previous addiction cycle.
• Identify support groups. Manyif not most individuals who haveaddictions and become abstinent doso without using pharmacologic intervention.Traditionally, clinicians havereferred people to 12-step programs likeAlcoholics Anonymous and NarcoticsAnonymous. Many patients have used12-step programs successfully, but othersmay not embrace them. Today, manyprograms are available that use differentapproaches. Identify them and talk withgroup leaders about how they differ fromor are similar to traditional programs.Also ask about their success rates.
• Exercise reasonable vigilanceso the health care team does not doinadvertent harm. Injudicious use ofprescription and OTC medications thatmay alter patients' vigilance and judgmentcan precipitate relapse.^5,9 Revieweach new prescription using the guidelinesin the Table. At every visit, ask thepatient to list all current medications,including OTC drugs and herbal supplements.
• Watch for comorbid psychiatric illness, especiallydepression, anxiety, and posttraumatic stress disorder,and refer appropriately. Today, many psychiatrists earnaddiction subspecialties and may be more helpful to patientswith dual diagnosis than those who do not.⁵
• Watch for insomnia and pain and treat appropriatelybefore they escalate. Many individuals report theirproblems with alcohol or substances started when theyhad trouble sleeping or were injured and treated for pain.In the abstinent patient, insomnia and pain represent treatmentchallenges, and nonpharmacologic interventions likerelaxation techniques and lifestyle changes are essential.Regardless, clinicians will need to treat moderate-to-severeinsomnia or pain; often, acetaminophen, nonsteroidal antiinflammatoryagents, antidepressants, anticonvulsants, andother drugs usually considered adjunctive may help. If habitformingdrugs must be used, the patient should see one prescriberand have prescriptions filled at one pharmacy.
• Know that chemically dependent individuals aremore likely to smoke than others. This population oftenneeds pharmacotherapy like bupropion or nicotine replacementand cognitive and behavior therapy to quit successfully.Using a program similar to the one that helped them kickalcohol or chemicals may improve their chances of success.If depression is a comorbidity, treating it first will improve thelikelihood of smoking cessation.¹¹
• Strive to individualize treatment just as youwould for any other chronic condition. Traditionally,experts advised that addicts would seek treatment whenthey hit rock bottom. Today, the thinking is that interveningearly and encouraging individuals to seek help is better—forthe addict, the addict's loved ones, and society. Motivationalinterviewing can help pharmacists establish rapport, elicitchange talk, and establish commitment from the patient:Express empathy, so you understand the client's perspective.Help patients see the difference between their real valuesand how they want their lives to be.Roll with resistance means accepting that disinclinationto give up an addiction or habit is natural rather thanpathological.Support self-efficacy means accepting when addictschoose to continue drinking or using, but helping theminch their inclination from not wanting the change to havingthe confidence to change; often this occurs in babysteps.¹² This also is useful with patients who are reluctantto adhere to treatment or medication.¹³

Increasingly, patients choose to use pharmaceuticals todeal with their addictions. Pharmacists need a workingknowledge of acamprosate, methadone, natrexone, and variousanticonvulsants used in addictions.

Table

Medication Guidelines forthe Recovering Addict

• When patients present with conditionsthat are self-limiting, educate them thatthey have a choice regarding the use ofmedications to control symptoms.
• Educate patients about nonpharmacologicinterventions that alleviate symptoms.
• Avoid sedating antihistamines, stimulatingdecongestants, and potentially moodalteringcough preparations.
• Be aware of OTC and prescription drugsthat are often abused (eg, amphetamines,benzodiazepines, dextromethorphan, carisoprodol,opioids, pseudoephedrine, andcombination products that contain opioidsor benzodiazepines), and suggest otherproducts.
• Recovering patients may hesitate orrefuse to use any medication, fearingrelapse. When medication is essential,good counseling and education can overcomethis fear.

Adapted from references 5,10.

References

• 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.