Debunking Myths About Medications

Understanding Their Role in Addiction Treatment

Medications can play a vital role in addiction treatment, yet people are often unjustly stigmatized for prescribing, dispensing, and taking them.  There are several myths surrounding medication therapy that are fueled by misinformation. This often deters people from accessing them. It is crucial for us to recognize that treatments for addiction, like any other chronic disease, must be tailored to the individual’s needs and adjusted over time. While some thrive without medications, others get very significant, even lifesaving, benefits from their use. Thus, a collaborative, shared-decision approach is needed to achieve optimal treatment adherence and sustained recovery.

The primary treatment objective when using medications for addiction is to mitigate cravings, reduce withdrawal symptoms, and support individuals in leading productive lives during their recovery journey. Before diving into common misconceptions, it is important to review the potential treatment options available for various substance use disorders (SUDs). With the increased publicity and stigma associated with medications for opioid use disorder (MOUD), particularly methadone and buprenorphine, it can be easy for us to forget that there are many treatments available for SUDs. Here’s a high-level overview of the FDA-approved medications for SUDs.

Medications for Substance Use Disorders

Debunking a Few Myths

Unfortunately, there are lots of myths about medications for SUDs.  Here are a few common ones:

Medications are just substituting one addiction for another.

This is probably one of the most common misconceptions I hear from patients, my students, friends, AND many health professionals. As a society, we often forget that “replacement therapy” has been used for years with nicotine addiction.  Smoking cigarettes causes lots of harm, and they contain a bunch of nasty chemicals that cause lung damage and increase the risk of heart disease and many cancers. The purpose of NRT isn’t to get someone “addicted” to a nicotine patch.  Rather, it’s to mitigate craving and reduce withdrawal symptoms so that the person is no longer thinking about smoking all of the time.  NRT is typically combined with smoking cessation counseling, giving the person a better chance of remaining smoke-free.  Some people use NRT for a few weeks.  Some people use NRT for years.  We’d much rather have a person use NRT than have a setback into smoking cigarettes again.  Sure, it would be great if the person didn’t need NRT and never had a desire to smoke cigarettes again.  But there is nothing “wrong” with using NRT.  Most people would agree that using NRT is perfectly acceptable and an important part of the recovery process for many people who smoke.

But for some odd reason, many in our society view medications for other addictions, particularly medications for opioid use disorder, very differently. This misconception fails to acknowledge the nuanced pharmacologic differences between heroin (and other drugs obtained on “the street”) and medications like buprenorphine and methadone. Unlike short-acting opioids, these medications are longer-acting and carefully dosed to limit feelings of euphoria while reducing, sometimes eliminating cravings. It is important to highlight that just as we use insulin to “replace” something the dysfunctional pancreatic can’t produce, medications for opioid use disorder address neurochemical deficits the brain is experiencing.  Remember, addiction is a neurobiological disease, and dopamine deprivation leads to discomfort and pain.  Without medication, many people will continue an endless cycle of intoxication/binge, withdrawal/negative affect, and craving/preoccupation.

You should not need medications for addiction long-term.

The notion that medication treatment should be taken for only a few weeks overlooks the fact that addiction rewires our brains.  Most people suffered through their addiction for many years before seeking treatment.  Establishing new habits (conditioning model) will take a significant amount of time (see Chaz Richardson’s blog post Addiction is a Neurobiological Disease). Consider your own habits you have tried to “break” – how long have you been trying to adjust your routine without success? Additionally, SUD medications vary in their effectiveness from person to person (just like any treatment!). Several factors influence the pace at which someone can reduce the dose and eventually taper off their medications, including the substance of misuse and the severity of the addiction. Rushing this process risks a setback in the recovery journey, and setbacks often have significant psychological as well as physiological consequences.  Therefore, we need to continually assess the person’s progress and engage in open discussions about when someone feels ready to begin the tapering process. Not everyone will succeed with the initial taper attempt.  Ultimately, there is no “recommended timeline” for patients to be maintained on medications for SUD.

Medication should not be started until someone has completed withdrawal and remains abstinent.

It’s true that certain medications require complete abstinence for a period of time before they can be safely used – otherwise, they could induce severe withdrawal symptoms. For example, naltrexone for OUD and disulfiram for alcohol use disorder. However, these medications are the exceptions. Many medications for SUD can be safely initiated when a person is experiencing mild to moderate withdrawal symptoms and even when someone is still using substances. Initiating medications in this early timeframe takes a harm-reduction approach that results in positive treatment outcomes. Current guidelines for OUD advocate for the initiation of methadone or buprenorphine as first-line therapy to prevent opioid withdrawal.¹ Abrupt cessation of opioids can trigger intense cravings and an acute withdrawal syndrome that, in turn, promotes drug-seeking behavior, overdose, and even death.

The buprenorphine/naloxone combination product should be the only burprenorphine product used for OUD.

This misconception may seem plausible.  Naloxone, after all, is supposed to deter misuse. However, the reality is more nuanced. When developing this product, pharmaceutical scientists identified the potential for buprenorphine misuse and included naloxone to deter diversion. However, naloxone is minimally absorbed orally and must be administered intravenously, intramuscularly, or by nasal spray to reverse an opioid overdose. Consequently, the naloxone component in the oral combination product has no effect unless the medication is crushed and injected. So yes, it can prevent misuse to a degree, but when taken as prescribed, naloxone has no effect. Opting for the combination product may be warranted if diversion and misuse are a concern. However, not everyone can tolerate this particular product, and some require an alternative formulation. We shouldn’t restrict access to buprenorphine based on this misconception.    

Although these misconceptions may appear harmless, they create significant barriers to care at both the individual and system levels. In 2022 alone, an estimated 54.6 million people needed treatment for a SUD, yet only 26% of those people received any help.² This is a very wide gap, and the reasons are multifaceted.  But anecdotally, I have witnessed stigma surrounding medications for SUD deter patients from seeking treatment, providers from prescribing them, and pharmacies from stocking them. At a system level, there are significant barriers to getting access to medications like buprenorphine and methadone. There are strict dispensing limitations for pharmacies, and methadone can only be obtained from a licensed OUD treatment facility rather than through a local pharmacy.

Medications for SUDs are intended to complement behavioral treatments but can be used alone.  It all depends on what the individual deems most effective for their recovery journey. Dispelling misconceptions and combatting the stigma surrounding these medications facilitates informed decision-making. By acknowledging the positive role that medications can play in addiction treatment, individuals can use a variety of strategies in recovery. Medications can improve a person’s sense of well-being, and there is strong evidence that they can increase the odds of sustained success. Let’s work together to debunk myths and foster an acceptance of medications for addiction.

Resources:

1. Crotty K, Freedman KI, Kampman KM. Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. Journal of Addiction Medicine 2020; 14(2): 99-112.

2. 2022 National Survey on Drug Use and Health (NSDUH) Releases. Accessed May 11, 2024.