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[C]ocaine or methamphetamine
...are...the drugs of choice for many people with bipolar disorders, probably because of their paradoxically--and temporary--calming effects....

Drug and Alcohol Detox/Dependency Aids


The following excerpt is taken from Chapter 4 of Bipolar Disorders: A Guide to Helping Children and Adolescents by Mitzi Walsh, copyright 2000 by O'Reilly & Associates, Inc. For book orders/information, call (800) 998-9938. Permission is granted to print and distribute this excerpt for noncommercial use as long as the above source is included. The information in this article is meant to educate and should not be used as an alternative for professional medical care.

When a young person has a dual diagnosis of chemical dependency and a bipolar disorder, most doctors choose to treat both conditions at once. This can be difficult unless the patient is in a hospital or other residential situation, where presumably he will not have access to drugs or alcohol. Doctors must also be careful about possible conflicts between medications for bipolar symptoms and medications used for other purposes.

Drug and alcohol withdrawal can be a painful process. Several neural and hormonal systems are affected by substance abuse, and when it ends they are thrown into confusion. Effects can include noradrenergic hyperactivity, gamma-aminobutyric acid (GABA)-benzodiazepine receptor alteration, elevated hypothalamic-pituitary-adrenal axis, and changes in the N-methyl-D-aspartate (NMDA) glutamate receptors. The patient's blood pressure may soar or become unstable, she may sweat profusely or develop tremors. Severe nausea and physical pain is also commonplace.

For years, inpatient detox programs have prescribed the benzodiazepine tranquilizers as a way to blunt these difficulties. Unfortunately, these medications are also addictive--and may encourage patients to simply trade one addiction for another. They are still widely used to treat withdrawal from methamphetamine and cocaine, however, simply because there are few other medical options.

Methadone treatment is another option for heroin addicts. It involves swapping an illegal addiction for a legal one, which is controversial. However, methadone treatment has been shown to help keep drug addicts away from criminal behavior, and to help them become more productive members of society. When combined with counseling and other strategies, it may be a good first step on the road to actual detox. It certainly can improve the patient's health in many ways, as methadone is administered in a clinic, comes in a reliable dose to eliminate the risk of overdose, and is drunk rather than injected. It is the treatment of choice for pregnant addicts.

Cold turkey detox is always an option--and for some people, it works best despite the temporary discomfort. However, today's addiction specialists do have pharmacological tools at their disposal that can ease the pain and suffering of addicts in detox, and help prevent relapses. Intensive rehabilitation centers for people addicted to heroin and other opiates can use a one-day detox method that involves completely sedating the patient and administering ReVia or another opiate blocker intravenously. Follow-up care consists of continued use of oral opiate blockers and counseling. Some programs are also experimenting with implanted ReVia. Few teenagers can gain admission to these programs.

Some intensive detox programs claim a 75 to 80 percent success rate, although this cannot be confirmed. The cost of such treatment ranges to well over $7,000.

Currently there are no cocaine or methamphetamine antagonists available for those who are addicted to these drugs (which are, unfortunately, the drugs of choice for many people with bipolar disorders, probably because of their paradoxically--and temporary--calming effects on some BP individuals). Several potential cocaine antagonists are currently under development, but so far there have been many roadblocks in this research. Cocaine works by preventing certain nerve cells from accumulating the neurotransmitter dopamine, making dopamine widely available to the brain and causing a euphoric high. Blocking dopamine entirely produces many ill effects on the body, however.

Heavy methamphetamine and cocaine abusers often experience the symptoms of psychosis. Neuroleptics are used to address these symptoms in some addiction treatment centers.

Supplementing with vitamin C, which can counteract the effects of prescription stimulants, may also help recovering methamphetamine addicts.

The tricyclic antidepressants, SSRIs, and BuSpar have shown some promise in helping recovering alcoholics stay sober. People with a bipolar disorder and substance dependency may find that recovery is easier if they use an antidepressant in addition to their regular mood stabilizer. Some doctors use clonidine or Tenex during drug or alcohol withdrawal.

For obvious reasons, young people with drug and alcohol addiction should not be given unfettered access to these or any other prescription medications. Doses should be given individually, and drugs should be securely stored. Counseling support, including 12-step programs, can be helpful in preventing the development of prescription drug abuse in recovering addicts.

The following are medications that may be used to treat or prevent substance abuse. It should be noted that their use is rare in treating teenage patients.

Acamprosate

Generic name: calcium acetylhomotaurinate

Use: Prevention of alcohol abuse.

Action, if known: Acamprosate is a calcium channel blocker. It seems to stimulate inhibitory GABA receptors and to antagonize excitatory amino acids, such as glutamate. This should prevent some of the pleasurable, reinforcing effects of alcohol use.

Side effects: Diarrhea

Tips: Acamprosate is available in Australia and several European countries, but is still in clinical trials in the US.

Antabuse

Generic name: disulfiram

Use: Prevention of alcohol abuse.

Action, if known: Antabuse works by inhibiting the enzyme acetaldehyde dehydrogenase, which normally breaks down the toxic by-product acetaldehyde that forms when the body metabolizes alcohol. If you drink alcohol while taking Antabuse, acetaldehyde builds up immediately and you will become violently ill.

Side effects: Drowsiness, mood swings, unusual sensations in the hands or feet (tingling or pain). Antabuse can cause or exacerbate heart or liver problems. Drinking large quantities of alcohol while taking Antabuse can actually kill you.

Tips: Antabuse should be used only as part of a complete recovery program, including counseling and peer support. People taking Antabuse should be monitored for heart and liver problems. They must also be careful to avoid healthcare and skin products that contain alcohol, including many cough syrups. In addition, they should avoid contact with the fumes of chemicals that may contain alcohol, acetaldehyde, paraldehyde, or other related substances, including paint, paint thinner, varnish, and shellac. Most doctors feel that Antabuse is of little or no help in treating alcohol addiction--it is sometime used as a punitive, court-ordered deterrence measure rather than a legitimate medical treatment.

Calan

Generic name: verapamil

Also known as: Isoptin

Use: Angina, heart arrhythmia, high blood pressure, prevention of alcohol abuse.

Action, if known: Calcium ion influx inhibitor.

Side effects: Dizziness, constipation, nausea. Lowers blood pressure, can cause edema (water retention in the ankles and legs).

Known interaction hazards: Do not use with beta blockers. Calan may lower your lithium level. Potentiates digoxin. Be careful with Calan if you use any other medication that affects blood pressure. May counteract or interact negatively with verapamil, Quinidine, Disopyramide, flecainide, neuromuscular blocking agents, carbamazepine, cyclosporine, theophylline. Counteracted at least somewhat by rifampin, phenobarbital, and Sulfinpyrazone. May interact with inhaled agents used in anesthesia.

Tips: Blood pressure and liver function should be monitored while taking this drug, especially in patients with known liver damage. Take Calan with food.

Narcan

Generic name: naloxone hydrochloride

Use: Treatment of opiate and narcotic overdose or addiction, reversal of the effects of anesthetics.

Action, if known: Opiate antagonist. Unlike ReVex and ReVia, Narcan counteracts all of the effects of morphine.

Side effects: May raise blood pressure, may lower the seizure threshold.

Known interaction hazards: Do not use with bisulfate or alkaline solutions.

Tips: Naloxone has not been well-tested in treating chemical dependency.

ReVex

Generic name: nalmefene hydrochloride

Use: Treatment of opiate and narcotic addiction or overdose, reversal of the effects of anesthetics.

Action, if known: Opiate antagonist. Appears to activate the hypothalamic-pituitary-adrenal (HPA) axis more strongly than naloxone.

Side effects: Anxiety, nervousness, insomnia, abdominal discomfort, nausea, headache, muscle or joint pain. May lower the seizure threshold.

Known interaction hazards: Alcohol and all central nervous system depressants, including anesthetics, narcotics, and sedatives. ReVia may block the effects of these substances until they reach a critical, even deadly, level.

Tips: Other than the difference already noted, ReVex is essentially the same as ReVia--see the next entry.

ReVia

Generic name: naltrexone hydrochloride

Also known as: Trexan, NTX.

Use: Heroin/opiate and alcohol addiction withdrawal aid, treatment of narcotic overdose, self-injurious behavior (SIB), reversal of the effects of anesthetics.

Action, if known: Opiate antagonist--blocks opiate chemicals.

Side effects: Anxiety, nervousness, insomnia, abdominal discomfort, nausea, headache, muscle or joint pain. May lower the seizure threshold.

Known interaction hazards: Alcohol and all central nervous system depressants, including anesthetics, narcotics, and sedatives. ReVia may block the effects of these substances until they reach a critical, even deadly, level.

Tips: According to product literature, ReVia should not be used by people who are currently addicted to drugs or alcohol--it is used only after the detox process is over, to help the person stay sober. However, a number of intensive detox centers do rely on ReVia, and it does appear to help reduce cravings for drugs and alcohol. People with liver problems must be closely monitored while taking ReVia. Recent studies indicate that ReVia (and possibly other opiate blockers) can help stop the cycle of self-injurious behavior.


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