The Value of Relapse Prevention Medication in Addiction Treatment: An Interview with Dr. Steven L. Batki

Relapse prevention medications are designed to reduce drug craving and the urge to use, with the goal of helping people achieve long-term abstinence. These medications are an important component of a recovery plan—and they have been empirically proven to reduce relapse rates, setting the stage for ongoing sobriety. “Relapse prevention medications,” Dr. Batki asserts, “play an absolutely essential role in recovery from addiction to alcohol, opioid, and tobacco—substances for which we have medications with proven relapse prevention effectiveness.”

Still, as Dr. Batki says, “We don’t have proven relapse prevention medications for all substances.” Currently, there are no medications with proven effectiveness for addiction to marijuana, hallucinogens, or stimulants such as cocaine or methamphetamine. But for the millions of people struggling with alcohol, opioid, or tobacco use disorders, there are safe and effective pharmacological treatments that have been shown to have a profound impact on treatment outcomes.

Not only do these medications reduce the impetus to use pharmacologically, they can also give you the psychological space to more fully participate in the healing process. Without the overwhelming cravings and constant obsession with using, you are able to engage in the therapies and self-reflection you need to create meaningful emotional and behavioral change.

Alcohol addiction is one of the primary substance use disorders for which relapse prevention medications exist, and these medications can be very helpful in both the early stages of treatment and for long-term recovery. Treatment options include:

• Naltrexone (in the oral tablet form): Naltrexone is an opioid antagonist that can be taken as a once-a-day oral medication that reduces cravings and decreases the pleasure of alcohol consumption. Patients with high levels of craving for alcohol may find naltrexone useful.

• Vivitrol: Vivitrol is naltrexone in a monthly, extended-release injectable form.

• Antabuse: Antabuse (disulfiram) is an oral medication that produces intensely unpleasant physical effects if alcohol is consumed by raising the levels of the alcohol metabolite acetaldehyde. People who want to place a barrier between themselves and alcohol may find it useful.

• Campral: Campral (acamprosate) is an oral medication that normalizes the brain activity that has been dysregulated as the result of chronic alcohol use, reducing withdrawal symptoms and reducing cravings. Campral can be challenging as patients need to take 2 pills 3 times a day.

• Topamax: Topamax (topiramate) is an anticonvulsant and migraine-prevention medication that normalizes neurotransmitter activity to reduce craving for alcohol. It can be very effective but has more side effects than other medications.

While not everyone who struggles with problem drinking needs pharmacological intervention, Dr. Batki believes that these medications can provide substantial benefits for anyone whose alcohol use has progressed to the point of needing treatment:

My view is that anyone who has a serious enough alcohol use disorder to require treatment also has a severe enough problem to require relapse prevention medication. All current national addiction treatment guidelines recommend that patients with serious alcohol use disorder be offered relapse prevention medication in addition to the rest of their recovery plan — just like anyone with severe depression would be offered antidepressant medication in addition to psychological treatments.

The intense physical dependence and neuroadaptive changes that result from chronic opioid use make opioid addiction one of the most challenging and difficult substance use disorders. As a result, preventing relapse to opioid addiction has been a prime area of medical investigation for decades, leading to the development of several effective medications that are now in widespread use. These include:

• Vivitrol: Vivitrol is a monthly, injectable form of Naltrexone, an opioid antagonist that acts on opioid receptors to block the effects of opioids and reduce craving. A single injection of Vivitrol can block the effects of heroin or other opioids for an entire month. Vivitrol is a treatment of choice for individuals who want to be opioid-free.

• Buprenorphine: Buprenorphine (Suboxone) is a partial opioid agonist that reduces the euphoria of opioids while suppressing craving and physical withdrawal symptoms. Unlike methadone, buprenorphine is available by prescription in physicians’ offices, and you do not need to be in a formal opioid treatment program to access the drug. Buprenorphine is much safer than full agonist opioids like methadone, morphine, or heroin.

• Methadone: Methadone is a full opioid agonist that blocks the high of opioids while reducing craving and alleviating withdrawal symptoms. Methadone may be used both in early recovery and as maintenance treatment, but is only available via highly regulated opioid treatment programs and often requires daily attendance at special clinics that provide this medication.

For most people suffering from serious opioid addiction, relapse prevention medications aren’t just an option, they are a necessity. “For someone who has severe enough opioid use disorder to come to treatment, it is very difficult to maintain abstinence without the use of relapse prevention medication,” Dr. Batki tells me. “In my 33 years of working with people who have serious heroin or other opioid use disorders, it’s difficult for me to recall more than a handful of patients who did not benefit from the use of relapse prevention medication to facilitate their recovery.”

Despite the immense benefits conferred by relapse prevention medications, they remain woefully underused, particularly in alcohol addiction recovery. A recent article published in the New York Times revealed that only 2% of those seeking treatment for alcoholism received relapse prevention medication, despite overwhelming evidence of its efficacy. Dr. Batki believes that moralistic, non-medical attitudes about the nature of addiction, recovery, and abstinence are partially to blame.

Part of it is rooted in a very narrow view of the recovery process that involves non-medical moral judgments about what treatments for addiction are acceptable. An extreme version of that philosophy holds that taking any sort of medication, even non-abusable ones such as Vivitrol, or antidepressants or mood stabilizers, is seen as a ‘crutch’ or something that maintains ‘dependency.’ Some addiction treatment providers don’t encourage patients to ask for these medications—or they actively discourage them.

This narrow interpretation of the meaning of abstinence stands sharply at odds with best medical practices and currently accepted treatment guidelines, and can create significant barriers to healing. At times, patients themselves are reluctant to try relapse prevention medications, in part because they have been told that it is at odds with an abstinence-based approach to recovery. But Dr. Batki sees things differently.

I define abstinence as abstinence from drugs of abuse. I don’t consider medications drugs of abuse, since treatment medications can help avoid relapse. Achieving abstinence from a drug of abuse requires the use of everything that’s scientifically proven to help – 12-step programs, counseling, and the use of relapse prevention medications.

He maintains that relapse prevention medication doesn’t interfere with abstinence, but instead helps create the path toward it.

Narrow views of what constitutes abstinence are not the only things standing in the way of widespread implementation of medically sound addiction treatment practices. Many physicians are not adequately trained to treat addiction, and are not familiar with relapse prevention medication. Physicians who don’t specialize in addiction medicine are often either unaware of these medications or don’t know how to use them. There’s also another problem: therapeutic nihilism. “Some physicians feel there’s nothing they can do to help addiction, so they don’t even bother, or they don’t make as much of an effort to treat addiction as they would high blood pressure or diabetes or other chronic medical illnesses.”

But Dr. Batki sees the tide turning. “Thankfully, there is growing number of addiction medicine physicians, including addiction medicine psychiatrists, who are helping to counter this trend,” he says. “Every day, more knowledge is being disseminated about the utility of these life-saving relapse prevention medications.”