Public Policy Statement on Pharmacological Therapy for Alcohol and Other Drug Addiction
Alcohol and other drug addiction is a major public health problem, accounting for significant morbidity and mortality across all segments of the population. There are established pharmacological treatments available for opioid and nicotine addiction, including agonist maintenance therapies. (See ASAM Public Policy Statements on “Methadone Treatment of Addiction,” “Buprenorphine for Opiate Dependence and Withdrawal,” and “Nicotine Addiction and Tobacco.”) In addition, there is now an expanding repertoire of pharmacological options designed to treat alcohol addiction. These newer medications can help patients initiate abstinence and can assist individuals involved in psychosocial treatments for alcohol addiction to reduce or eliminate alcohol use.
The eventual goal of any treatment of addiction is to assist the patient to attain and maintain a significant span of remission of active signs of their disease; this is comparable to the goals of treatment of any chronic relapsing/remitting general medical illness. The ideal outcome is lifetime remission: the pathological process may not be eliminated, but manifestations of active disease (signs/symptoms) are quiescent. As of the early 21st century, available medication management of opioid and nicotine addiction is effective for many patients, while pharmacotherapies for alcohol addiction are less likely to generate such complete results, especially in the absence of active patient engagement in psychosocial therapies. Nonetheless, the evidence of the ability of newer pharmacotherapies to help treat alcohol use disorders is sufficiently encouraging to warrant recommendations that such treatment approaches be seriously considered, both by persons with alcohol addiction and the health care professionals who manage their care.
1. The American Society of Addiction Medicine recognizes addiction as a primary brain-based disease with multimodal causes and treatments. Accordingly, ASAM supports and recommends access to all evidence-based treatments for addiction, including psychosocial and pharmacological therapies. Treatment planning should be individualized to the needs of the patient. In the development of treatment plans for addiction, neither psychosocial therapies nor pharmacologic therapies should be excluded a priori as treatment options.
2. Physicians treating addiction should proceed just as when they treat other conditions, taking their training and experience into account and using medications which they believe are in the patient’s best interests, whether the medication is FDA-approved for that indication or not.
3. In the past, local, state, and federal agencies have restricted the use of some medications such as methadone and buprenorphine. ASAM does not support regulation to limit dosage, number of patients treated, or prohibition of the use of any FDA-approved medication, even if closely-monitored off-label, that an appropriately trained physician chooses to use.
4. Following models of effective and established treatment for other chronic disorders that have combined biological and psychosocial components (such as major depressive disorder and juvenile diabetes), practitioners and payers should consider the combination of psychotherapeutic/psychosocial treatment and pharmacotherapy as a primary strategy in the treatment of addiction so as to reduce relapse and support ongoing, stable recovery.
5. ASAM recommends comprehensive evaluation for each patient with an addiction and supports that, in some cases, such evaluation will result in a recommendation of pharmacotherapy as a first-line treatment strategy, not simply a treatment to be considered after a “failed trial” of psychosocial therapy.
6. ASAM recommends that especially in those cases where patients have engaged in multiple episodes of psychosocial rehabilitation and have encountered relapse to active addiction, patients should be evaluated by a physician knowledgeable about addiction treatment. That physician may make a recommendation that the use of a pharmacological therapy would likely improve treatment outcome.
7. When patients with addiction are referred to medically monitored or clinically managed addiction rehabilitation services (for definitions of such levels of care, see the ASAM Patient Placement Criteria ), patients should not be excluded from consideration for admission on the basis of their being prescribed a pharmacological therapy for addiction.
8. ASAM recommends that increased resources be devoted to education about the appropriate use of pharmacological treatments for addiction, in order to dispel misunderstanding and stigma about pharmacotherapies such as methadone, buprenorphine, and medications for alcohol use disorders. Such educational efforts should be directed to physicians in both primary care and medical specialties, and should also be directed to physician assistants, addiction counselors, therapists, psychologists, nurses, nurse practitioners, and other health professionals.
9. Physicians should be able to prescribe medications for the treatment of addiction based on medical evidence as reported in clinical literature and on their clinical judgment. ASAM supports and recommends that evidence-based FDA-approved pharmacotherapies for addiction be present on all formularies of all major health plans (including commercial plans, indemnity plans, PPOs, and HMOs) and public financing systems (including Medicare, Medicaid, TriCare, the Department of Veterans Affairs, and the Indian Health Service).