Why are benzos not used as a harm reduction method for alcohol use disorder?

[nighthawk2551]

At first glance this sounds like a dumb idea but I can't think of anything wrong with it. In people with moderate to severe alcohol use disorder, why do we not prescribe benzos as a means to give people their GABA kick in the hopes they do not use alcohol? From my understanding, besides the addiction aspect the vast majority of negative health effects from alcohol come from the toxicity of alcohol itself. It increases cancer risk in basically every body part it touches (head and neck, esophageal, stomach), its breakdown products are terrible for the liver, and it is neurotoxic and can lead to Wernicke-Korsakoff. I've never used a benzo, but I hear they are remarkably similar to alcohol. Why would it not work to prescribe an alcohol benzos in the hope they stop using alcohol because the benzo gets rid of their cravings, then taper down the benzo. Of course there would be a risk of overdose or adverse reactions if mixed with alcohol, but the same could be said for methadone.

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[OldPsychDoc]

In one word: tolerance.
And you're not "giving back a GABA kick"--you're just further suppressing it with the benzos.

There are better GABAergic options--gabapentin, baclofen, etc.
Safer for the liver than diazepam or clonazepam, too.

 

[siliso]

I have heard of baclofen and gabapentin being used in this way with some success. Benzos I’d be worried they’d get used to potentiate alcohol enjoyment in people who aren’t looking to abstain, with potentially dangerous consequences, and also the legal ramifications of controlled substance prescribing. Also alcohol is like dirtier neurochemically than just the GABA and benzos may not fulfill the need/craving in the way that say methadone can for opioids. But the idea is interesting, maybe worth studying.

 

[siliso]

A related question - why not use adderall for harm reduction/maintenance in meth addicts? I had a patient ask me for this recently and had to decline since one of my life goals is avoiding federal prison, but I couldn’t argue with the logic of it.

 

[Ironspy]

A related question - why not use adderall for harm reduction/maintenance in meth addicts? I had a patient ask me for this recently and had to decline since one of my life goals is avoiding federal prison, but I couldn’t argue with the logic of it.

This is done by some attendings I know as a harm reduction strategy. I’m not so enlightened myself

 

[nighthawk2551]

In one word: tolerance.
And you're not "giving back a GABA kick"--you're just further suppressing it with the benzos.

I'm not sure what you mean by this? How are benzos suppressing GABA activity?

There are better GABAergic options--gabapentin, baclofen, etc.
Safer for the liver than diazepam or clonazepam, too.

Sure, but those benzos are way safer for the liver than alcohol.

 

[siliso]

People get drunk for a lot of reasons other than for anxiolysis and getting real sleepy and going to sleep, which is all more or less that benzos can do for you. I think a Xanax party would be a lot more boring than a cocktail party for a number of reasons.

“It is clear that ethanol affects brain function by modulating numerous neurotransmitter systems including but not limited to, GABA [1,2], glutamate [3], serotonin [4], norepinephrine [5], neuropeptide Y [6], vasopressin [7], adenosine [8] and dopamine (DA) [9–11].”

Exploring the Neurochemical Basis of Alcohol Addiction-Related Behaviors: Translational Research

This Editorial presents the position that translational research continues to play a vital role in the field of alcohol addiction research. Using diverse animal models that mimic fundamental features of the disease, tremendous progress has been made in ...

www.ncbi.nlm.nih.gov

If you only hit GABA it wouldn’t necessarily satisfy the craving to get sloshed, given the lack of dopamine etc stimulation. Other drugs have better 1:1 type pharmaceutical analogs. Even then there are still social/behavioral aspects to addiction that aren’t solved just with substitution, I acknowledge, but at least to get people away from dirty needles and a life of crime focused on getting and using is a big win.

 

[Sushirolls]

I believe the benzo substitute theory was looked into years ago research wise, and data was quite poor, thus current practice to not do that.

 

[Attending1985]

A related question - why not use adderall for harm reduction/maintenance in meth addicts? I had a patient ask me for this recently and had to decline since one of my life goals is avoiding federal prison, but I couldn’t argue with the logic of it.

Because they will abuse the stimulant and a problem will be created not solved

 

[siliso]

The problem exists for the addicted people already though. And even those motivated to abstain will experience the brutal depression and fatigue and anhedonia of all their lonely empty upregulated dopamine and norepi receptors, driving them back into the arms of (dirty, infection spreading, property and family destroying, crime cartel supporting) meth. If MAT is standard of care for OUD...why not for amphetamine?

 

[Ceke2002]

Because they will abuse the stimulant and a problem will be created not solved

Pretty much. When I was abusing meth, 20 odd years ago now, the group I hung with would occasionally try to alleviate the urge to 'party' by substituting with excess doses of dexamphetamine. It never worked, and invariably just lead to more intense cravings for meth instead. I'm surprised any physician would even consider this even as a potential harm minimisation strategy.

 

[siliso]

I’m emphatically not even considering providing it myself outside of standard of care, just wondering about possibilities for research into whether harms could be reduced.

 

[siliso]

What I wasn’t sure in reading through DEA directives is whether I’d have adequate cover to say it was legitimate and generally accepted medical practice, or whether instead it could be construed as “dealing” a sched ii substance to sustain a person’s addiction outside of our legit MAT and non mat recovery programs.

 

[LadyHalcyon]

I've seen modafanil used at treatment centers for this purpose

it is used for this. there is some literature describing it and I definitely know people who do this in clinical practice. definitely not something that is going to get you imprisoned or attract unwanted attention from the DEA.

 

[NickNaylor]

A related question - why not use adderall for harm reduction/maintenance in meth addicts? I had a patient ask me for this recently and had to decline since one of my life goals is avoiding federal prison, but I couldn’t argue with the logic of it.

I've also always wondered about this. It is fundamentally, in my mind, no different ORT in terms of the overall strategy. Many of the same risks exist in ORT, and yet I doubt you'd get the same response to this strategy as you would to ORT.

Unless I'm missing something, essentially all of the same concerns brought up could be just as applicable to ORT, yet ORT is arguably the gold standard for OUD.

 

[Georgit]

MAT is standard of care for OUD...why not for amphetamine?

There is literature about this, daily plain amphe ( adderall XR) for meth addicted?
It i an obvious idea, curios to know if it works.
And amphe for coke addicted? I think this can not work

 

[LadyHalcyon]

There is literature espousing some people abuse stimulants as a way to self-medicate undiagnosed/untreated mental health disorders, such as ADHD and MDD. Curious as to thoughts on that premise......

There is literature about this, daily plain amphe ( adderall XR) for meth addicted?
It i an obvious idea, curios to know if it works.
And amphe for coke addicted? I think this can not work

 

[Georgit]

Pretty much. When I was abusing meth, 20 odd years ago now, the group I hung with would occasionally try to alleviate the urge to 'party' by substituting with excess doses of dexamphetamine.

Do yuo feel that dextro is so different from racemic/levo?
According to Sthal's book(*)they are pretty similar , but that is clearly bunk

(*) He also states that cocaine is inactive by oral route. The chapter about addiction is pretty poor.

 

[Georgit]

There is literature espousing some people abuse stimulants as a way to self-medicate undiagnosed/untreated mental health disorders, such as ADHD and MDD. Curious as to thoughts on that premise......

But a switch from meth to supervised Adderal was never tried? Some case studies I mean
The try, the idea is more tha obvious from a harm reduction point of view.
Mayebe the whole thing is too much socially and morally loaded, and this spills into clinical practice.

 

[LadyHalcyon]

An open-label pilot study of methylphenidate in the treatment of cocaine dependent patients with adult attention deficit/hyperactivity disorder


A multi-site, open-label study of methylphenidate for treating patients with comorbid diagnoses of attention deficit/hyperactivity disorder and cocaine dependence was performed. Forty-one participants, who met DSM-IV criteria for adult attention deficit/hyperactivity disorder and cocaine dependence, were enrolled into this ten week outpatient study. The targeted total daily dose of methylphenidate was 60 mg (20 mg TID). Participants received individual substance abuse therapy throughout the trial. Safety measures included adverse events, vital signs, and electrocardiograms. Methylphenidate's efficacy was assessed by both objective and subjective measures. Seventy percent of the participants completed final study measures. Safety measures indicated that methylphenidate was well tolerated by the participants. Subjective efficacy measures suggested that participants evidenced improvement in both cocaine dependence and adult attention deficit/hyperactivity disorder symptoms. Quantitative benzoylecgonine indicated that only those participants categorized as being compliant showed improvement. A double-blind, placebo-controlled study of methylphenidate for this population may be warranted.

But a switch from meth to supervised Adderal was never tried? Some case studies I mean
The try,the idea is more tha obvious from a harm reduction point of view. Mayebe the whole thig is too much socially and morally loaded, and this spills into clinical practice.

I do find it interesting that Ritalin reduced cocaine use, but they did not follow-up to see whether they would have abused Ritalin later. Additionally, studies measuring substance use with self-report measures are pretty much useless imo.

Eta: This article is fairly thorough and touches on concepts in this thread
Treatment Strategies for Co-Occurring ADHD and Substance Use Disorders

 

[Ceke2002]

Do yuo feel that dextro is so different from racemic/levo?
According to Sthal's book(*)they are pretty similar , but that is clearly bunk

(*) He also states that cocaine is inactive by oral route. The chapter about addiction is pretty poor.

I can't comment from a medical viewpoint, seeing as I'm not a Doctor, but from my own personal experience I'd have to say yes, the two are very different in terms of the high they both produce. Still didn't stop us from trying to reduce our meth use by substituting with dexies at least once a month or so, which inevitably failed each and every time. If anything the use of dexamphetamine increased our cravings for meth more than if we'd simply decided to take no amphetamine based drugs at all.

 

[dl2dp2]

A related question - why not use adderall for harm reduction/maintenance in meth addicts? I had a patient ask me for this recently and had to decline since one of my life goals is avoiding federal prison, but I couldn’t argue with the logic of it.

There's a fairly solid evidence base for high dose long-acting stimulants (in particular XR amphetamine) for cocaine treatment, especially in particular for co-morbid w. ADHD (~ 60% of the group). You can search for them > 5 studies, various formulations, several large high-quality RCTs, one multi-site, typically positive, a range of effect sizes, and multiple review articles. Typically the worse the ADHD the better the effect on cocaine (makes sense, right?).

There are stimulant-based trials that are ongoing for crystal meth, several different strategies. If you are interested we can talk more offline, but existing trials are either too small or haven't detected an effect, and various reasons were hypothesized.

The point being, these are good ideas, NIH is thinking about it and does some work, and there are pharma studies for newer agents. For older agents, some people (especially skilled addiction psychiatrists) use them off label in the right group, but the studies are more sparse due to lack of funding, etc.



W.r.t. benzo for alcohol, that's been also tried. If you search the lit this is one of the oldest strategies that was tried. Bottom line is the reason people don't do it is because it doesn't work. Proved by RCTs.

 

[whopper]

The problem with the suggestion is that 1) How is this not enabling the person's addiction problem? E.g. if an alcoholic gets violent cause he's mad when he doesn't get his booze, so you tell his family to buy booze for him that's pretty much enabling it. 2) With addiction, the amount the person takes is often times not a steady-state. E.g. if someone's addiction is to a sedative, that sedative will reach a point where the person needs it just to feel normal and then may demand more. On this specific point there is data that with opioids a steady-state could be reached but this will be very difficult for over 99% of clinicians to find out for sure cause it'd require pretty much full-time observation of the patient.

In regards to Sluox's above post, there's data showing if the person has comorbid ADHD, you treat it, the substance abuse gets better, not cause of risk-management but cause the ADHD was likely the underlying problem the abused stimulant was treating.

Stimulants could also have benefits with depression, but from the data I've seen (and I havent-re-reviewed the data for a few years) this is only beneficial for a few weeks tops, then the benefits plateau and the person forms some tolerance to them.