Use of psychoactive medicines (PAMs) is common in people undergoing office based opioid treatment (OBOT). PAMs have a misuse potential but can they disengage patients from continuing OBOT? Dr Zoe Weinstein et al of Boston University recently investigated the role of PAMs in disengaging patients on buprenorphine treatment and found them to play no role in 6-month treatment.
It is common knowledge that drug addicts are often suffering from other health conditions (such as depression, HIV), social, legal, occupational and familial problems that need to be addressed simultaneously. The best OBOT programs provide customized therapies to meet individual needs. Use of psychoactive medicines such as antidepressants, anxiolytics, antipsychotics and mood stabilizers are usually critical for a complete recovery.
Drug addiction therapists are also aware of the fact that most of the people with severe drug addiction abuse multiple drugs, including PAMs and those prescribed for post-traumatic stress disorder, bipolar disorder and schizophrenia.
The US Centers for Disease Control and Prevention (CDC) calls drug addiction a global epidemic. Everyday 78 Americans die of opioid overdose.
“From 2000 to 2014 nearly half a million people died from drug overdoses,” says a 2016 fact sheet published on CDC website.
It further says, “More people died from drug overdoses in 2014 than in any year on record. The majority of drug overdose deaths (more than six out of ten) involve an opioid. And since 1999, the number of overdose deaths involving opioids (including prescription opioid pain relievers and heroin) nearly quadrupled.”
Zoe Weinsten, MD, Instructor Boston University School of Medicine and corresponding author of the study, investigated the role of PAMs, such as gabapentin, clonidine and promethazine, in disengaging patients from OBOT treatment.
Gabapentin (Neurontin) is an anticonvulsant that is used to treat seizures, restless leg syndrome, hot flashes and neuropathic pain. It works by binding to voltage gated calcium channels in nerves and attenuates pain.
Clonidine, on the other hand, is a hypotensive agent and is used to treat high blood pressure, attention deficit hyperactivity disorder (ADHD), migraine and diarrhea etc. It works by reducing peripheral vascular resistance and smoothing blood flow.
Promethazine is an antihistamine that is used for allergy and nausea and vomiting associated with motion sickness. It has a strong sedative action.
There is an emerging evidence that patients misuse psychoactive medicines. In a retrospective analysis, Weinsten and colleagues collected data of a cohort from 2002 till 2014 and examined the association between use of PAMs and 6-month disengagement from OBOT. This is what they found.
At the time of the study, 43% were on PAMs – 562 patients out of the cohort of 1,308. The researchers found no association between PAMs and 6-month buprenorphine disengagement. However, they noticed that compared to phenothiazine, gabapentin and clonidine may be associated with a short-time disengagement.
The researchers concluded that the use of PAMs is safe during OBOT. However, it is a retrospective cohort analysis and definitely merits more research before a definitive conclusion could be drawn. Moreover, the study did not question or investigate the role of anti-opioid drugs, such as buprenorphine, naloxone and methadone, that are used in OBOT in causing dependence themselves despite the fact that the study involved buprenorphine as an opioid withdrawal treatment.
The study was published in Drug and Alcohol Dependence journal on November 5th, 2016.
How Can Psychoactive Medicines Disengage Patients From Continuing OBOT?
Clonidine, although hypotensive in nature, is also used to treat withdrawal from alcohol, opioids and nicotine. It does so by reducing sympathetic nervous system response to opioids, including fast heartbeat, high blood pressure, restlessness and hot and cold flashes. However, it does have an abuse potential itself as well.
As per a 2014 report published in the Journal of Addiction Medicine, just like opioids such as methadone, codeine or heroin, clonidine too has an abuse potential. It boosts the ‘high’ of opioids and reduces the dose of psychoactive drug needed.
Moreover, it may be easier to acquire than other drugs of abuse due to its low cost and limited awareness of its abuse potential.
Like all other anti-allergic drugs, phenothiazine makes you drowsy and like other tranquilizers, it too can be highly addictive. Phenothiazine misuse among methadone maintenance patients is well established.
Gabapentin, too, has become a drug of abuse. Its nonmedical use is on the rise. Patients on methadone maintenance programs find solace in gabapentin and trust the drug to give them the much coveted “high”. This can put them at risk of accidents, injuries and even death.
Psychoactive drugs are a viable alternative for the high of opioids. When used in conjunction with OBOT, these drugs can render the treatment unsuccessful and trigger a short-term disengagement in patients undergoing OBOT.