Drug dependence treatment

What is drug dependence?

Drug dependence is when the body has become so used to having that drug regularly that it needs that particular drug to function normally, and if it is stopped the body feels unwell. Previously dependence, tolerance and addiction have been called drug abuse, but this is no longer the preferred term. Substance use disorder covers the full range of problems that can occur.

Some drugs that cause dependence include:

• Nicotine.

• Morphine.

• Heroin (also known as diamorphine).

• Cocaine.

• Amphetamine.

• Alcohol.

In addition some people can become dependent upon medicines that are prescribed or bought from their local pharmacy. People who have drug dependence may have psychological dependence and/or physical dependence and/or tolerance to a particular drug.

Psychological dependence means having a craving or being compelled to use a particular drug to give pleasure or to stop from feeling bad - even though it may be dangerous to take the drug.

Physical dependence means that if the drug is stopped suddenly withdrawal symptoms are felt. For example, being dependent on heroin and stopping this drug suddenly will produce the following symptoms:

• Sweating.

• Feeling hot and cold.

• Runny eyes and nose.

• Yawning.

• Being off food.

• Stomach cramps.

• Feeling sick (nausea) or being sick (vomiting).

• Diarrhoea.

• Tremor.

• Poor sleep.

• Restlessness.

• General aches and pains.

• Just feeling awful.

Tolerance is usually a part of dependence. It means needing more and more of the same drug to give the same feeling as the smaller amount used when that drug was first taken.

Examples of some drugs that cause dependence include nicotine, morphine, heroin (also known as diamorphine), cocaine, amphetamine and alcohol. Some people can also become dependent on medicines that are on prescription. Examples are:

• The Z drugs (called thus because they begin with the letter Z: zopiclone, zolpidem and zaleplon).

• Benzodiazepines (for example, lorazepam, lormetazepam, diazepam).

• Codeine.

• Other medicines that can be bought from pharmacies - for example, over-the-counter painkillers.

Addiction is slightly different to dependence although the words are sometimes used interchangeably. If addicted to a drug, there is an excessive craving, and uncontrollable and compulsive use of that drug.

People who are addicted still get cravings for drugs such as opioids even after they have reduced them slowly so that they are no longer dependent. Some people are more likely to develop addiction than others, and seem to be particularly sensitive to the cravings. People can develop dependence on a drug but not be addicted.

This leaflet gives a brief overview of the medicines that are used to treat dependence on opiates (such as heroin), stimulants (such as cocaine), alcohol, nicotine, benzodiazepines and Z drugs.

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When you buy from your local pharmacy or receive your prescription, you know that you're getting a medicine that has been rigorously tested and found to be safe and beneficial for your condition. However, when you buy from some online retailers or from an unlicensed supplier, there's no guarantee that what you're buying will be real.

by Milly Evans

Treatment and medication

Complementary and alternative medicine

Complementary and alternative medicine (CAM) is used by many people. It can have a very good effect on improving well-being and may be helpful in relieving some symptoms. However, although there is some evidence from clinical studies that CAMs may work for certain symptoms, the evidence isn't very strong and it is impossible to draw firm conclusions about the benefits of each treatment. It is very important to consider whether any CAM treatment may have side-effects. Again the side-effects of some CAM treatments, particularly some herbal remedies, are not as well known as for conventional medicines. In addition, choosing to use alternative medicine instead of medically recommended treatments can sometimes be dangerous.

by Dr Colin Tidy, MRCGP

How can medicines help drug dependence?

Medicines for drug dependence are mainly used to reduce or prevent withdrawal symptoms. In the short term they help to stabilise the person's drug use and lifestyle while trying to break drug use. In the long term these medicines may help to change the person's drug taking and any risky behaviour.

Sometimes other medicines may be prescribed in addition to the medicine that helps to treat withdrawal symptoms. For example, for acute alcohol withdrawal symptoms, haloperidol or olanzapine may be prescribed for hallucinations.

Some drug users are often dependent on more than one drug and they may need a combination of medicines to help with dependency.

Which medicines are available to help with drug dependence?

There are several medicines that are used for drug dependence. The choice of medicine prescribed will depend on which drug:

Opiates (such as heroin or morphine)

Medicines used to treat opiate withdrawal and dependency include:

• Methadone.

• Buprenorphine.

• Lofexidine.

• Naltrexone.

Stimulants (such as cocaine or amphetamines)

Medicines used to treat amphetamines dependency include:

• Benzodiazepines such as diazepam.

• Antidepressants such as fluoxetine and lofepramine.

• Dexamphetamine.

Alcohol

Medicines used to treat alcohol dependency include:

• Chlordiazepoxide - to help at first with acute withdrawal.

• Carbamazepine or clomethiazole - for acute withdrawal.

• Haloperidol or olanzapine - for hallucinations during acute withdrawal.

• Acamprosate, naltrexone and disulfiram are used long-term to help prevent drinking re-starting.

Benzodiazepines

Medicine used to treat benzodiazepine dependency include:

• A longer-acting benzodiazepine (normally diazepam) is usually prescribed to people who are dependent on short-acting benzodiazepines as this is less likely to produce withdrawal effects. The dose of this can then very slowly be reduced.

Nicotine

Medicines used to treat nicotine dependency include:

• Nicotine replacement therapy (NRT) such as patches, gum and sprays, bupropion.

• Varenicline.

NRT is best used as part of a smoking cessation programme.

How are medicines used to treat drug dependence?

Opiates (for example, heroin, morphine, dihydrocodeine and codeine)

Treatment for opiate dependence involves replacing the opiate being used with a prescribed opiate. At the start of treatment the main aims are:

• To treat and prevent withdrawal symptoms.

• To reduce the risk of harm that is caused to the person and the community because of the drug use.

Once stabilised, the dose of the medicine may be gradually reduced with the aim of stopping altogether. Methadone is the opiate that is usually prescribed but another opiate called buprenorphine may also be used. Sometimes other opiates are used - for example, diamorphine, dihydrocodeine, or slow-release morphine tablets.

Stimulants (cocaine and amphetamines)

Unlike opiate dependence, there is no clear guidance on which medicines should be prescribed for people who are dependent on stimulants such as cocaine and amphetamine. As discussed above, benzodiazepines (such as diazepam) can help the patient to 'come down'.

However, this medicine is normally only used for less than two weeks. Supportive 'talking treatments' (psychological therapies) seem to be more effective than medication.

Other medicines may be tried by specialist doctors if there is also dependence on other drugs. For example, a medicine called disulfiram may be prescribed if there is also dependence on alcohol. Methadone, buprenorphine and dexamphetamine are sometimes used if there is also dependence on opiates such as heroin.

Sometimes an antidepressant (selective serotonin reuptake inhibitor (SSRI)) may be used if there is also depression. However, stimulants must be stopped before an SSRI is prescribed.

This is because if an antidepressant SSRI and cocaine are used together serotonin syndrome (overstimulation of the nervous system) can develop. This can make people very unwell.

Beta-blockers are useful if there is anxiety during withdrawal and they can help prevent cocaine use.

Alcohol

A doctor usually prescribes a high dose of medication such as chlordiazepoxide or diazepam (normally used by a specialist doctor in hospital) for the first day of stopping drinking alcohol.

Then the dose is slowly reduced over the following 5-7 days. This usually prevents, or greatly reduces, the unpleasant withdrawal symptoms. This is called detoxification, or detox. Taking the medicine for several months may be advised to help keep off alcohol:

• • Acamprosate is a medicine which helps to ease alcohol cravings. It is usually started in hospital and continued by GPs.

  • Naltrexone is an alternative to acamprosate but it is usually only prescribed by specialists.

  • Disulfiram is another medicine which is sometimes recommended by hospital specialists following a successful detox. It is better known as the name of one of the brands, Antabuse®. Whilst taking disulfiram very unpleasant symptoms occur if any alcohol is drunk - for example:

    • Flushing.

    • Being sick (vomiting).

    • A 'thumping' heart (palpitations).

    • Headache.

    • So, in effect, disulfiram acts as a deterrent for when people are tempted to drink. It can help some people to stay off alcohol.

  • Nalmefene is a newer medicine which is sometimes recommended by specialists to help people cut down on very excessive alcohol intake.

For more information see the separate leaflet called Alcohol Withdrawal (Alcohol Detoxification).

Benzodiazepines and Z drugs

Some people can stop taking benzodiazepines and Z drugs without any difficulty. However, for a lot of people the withdrawal effects are too severe to cope with if the medicine is stopped suddenly.

Therefore, it is often best to reduce the dose gradually over several months before finally stopping it. This keeps withdrawal symptoms to a minimum.

A common plan is to switch from whatever benzodiazepine tablet or Z drug that is being taken to diazepam. Diazepam is a long-acting benzodiazepine that is commonly used.

The doctor will be able to prescribe the dose of diazepam equivalent to the dose of the particular type of benzodiazepine or Z drug.

After this, it can be decided with a doctor how to reduce the dose gradually. Normally the dose is reduced by a small amount every 1-2 weeks. The amount the dose is reduced at each step may vary, depending on how large a dose is being taken to start with.

Also, the last few dose reductions before finally stopping completely may be less than the original dose reductions and done more gradually.

Sometimes other medication may be prescribed to help cope with symptoms while coming off benzodiazepines. For example, antidepressants may be offered if depression emerges whilst the person is on a withdrawal programme, or beta-blockers are needed to help control anxiety.

Nicotine

Either NRT, bupropion, or varenicline can be prescribed for people who want to stop smoking. The treatment is chosen after a discussion with a pharmacist, doctor or nurse about the pros and cons of each of the treatments.

NRT (Nicotine Replacement Therapy)

This is available as:

• • • • Gum.

      • Skin patches.

      • Inhalers.

      • Tablets/lozenges

      • Nasal spray.

      • Mouth spray.

Once the treatment is decided, a date is usually set to start. Some people prefer to stop smoking at the end of one day and start NRT when they wake the following day.

Others prefer to use NRT while they are still smoking, as a way of cutting down gradually. NRT is used regularly at first for at least 8-12 weeks. A high dose is normally started which is reduced in the later part of the course and then stopped.

It is not recommended to combine NRT with other medicines that help stop smoking, such as bupropion or varenicline.

Bupropion

One tablet is normally taken each day for six days. Then it is increased to one tablet twice a day, at least eight hours apart. Then a target date is set to stop smoking - usually one to two weeks after starting treatment.

This allows bupropion to build up in the body before stopping completely. The tablets are continued for a further seven weeks - eight weeks in total.

Blood pressure may go up while taking this medicine and fits (seizures) have also been reported with this medicine - this is rare. See the separate leaflet called Bupropion (Zyban) for more details.

Varenicline

Start by deciding on a quit date. Then start taking the tablets one week before the quit date. The aim is to build up the dose so the body gets used to the medicine before the quit date.

The usual advice is to start with a low dose and build this up over the following 11 weeks. The usual course of treatment is for a total of 12 weeks but, in some cases, an additional 12 weeks of treatment may be advised. See the separate leaflet called Varenicline (Champix) for more details.

What is the outlook for people with drug dependence?

The outlook for people with drug dependence provides good reasons to try and achieve recovery. For example, the mortality risk for people dependent on diamorphine is thought to be around 12 times that of the general population.

A long-term study of male opioid users in America found that after 24 years, 29 out of 100 were abstinent, 28 had died, 23 were still using opioids, and 18 were in prison.

After looking at the available studies, one review found that among survivors of people who had used heroin, 40 out of 100 eventually attain stable remission (over 10-20 years). The outlook is worse for those who have a co-existing mental health condition or chronic health problem such as diabetes.