Anticonvulsants Can Help, but How?
Glazer, William M., Behavioral Healthcare
Anticonvulsant medications appear to help in maintenance-phase SUD treatment, but no one knows exactly why
Substance use disorders (SUD) are treated with a variety of pharmacological agents. For example, it is standard practice to see medications including Clonidine, barbiturates, and benzodiazepines prescribed for acute withdrawal syndromes from alcohol, sedative-hypnotic medications, opioids, and nicotine.
For later, maintenance phases of SUD treatment, there are at present a limited number of labeled medications. For maintenance-phase, alcohol-abuse treatment, we see disulfiram (Antabuse), naltrexone (Depade, Nalorex, Opizone, Vivatrol, and others), plus acamprosate (Campral). For maintenance-phase opiate use disorder treatment, we see buprenorphine (Buprenex, Subutex, Transtec), methadone (Dolophine, Methadose, Metharose, and others) and the buprenorphine/naloxone (Suboxone) combination. Patients in the maintenance phase of SUD treatment may also be prescribed antidepressant, antianxiety, and/or antipsychotic medications that target coexisting mania, psychosis, anxiety, depression, or other psychological conditions.
More recendy, anticonvulsant medications have assumed a greater role in the pharmacologic management of SUD maintenance-phase treatment. At one time, these agents were routinely prescribed for withdrawal states associated with a high risk of seizures, but more recendy have been used to impact cognitive, behavioral, and symptomatic dimensions of SUDs.
Dr. Robert Post, Professor of Psychiatry at George Washington University School of Medicine, was a pioneer in the development of a role for anticonvulsants in treatment of bipolar disorder. He maintains that "some of the mechanisms riiat are pertinent to blocking seizure discharges in epilepsy may also be applicable to the broad uses of the anticonvulsants [in the treatment of] neuropsychiatrie disorders, including SUDs." Indeed, clinicians have employed anticonvulsants off-label to treat conditions ranging from anxiety disorders, substance abuse disorders, and migraines to eating disorders and obesity.
While the FDA has not approved any anticonvulsant for use in SUD treatment, many experts believe that they can play a role SUD treatment.
Dr. Jayesh Kamath, Assistant Professor of Psychiatry at the University of Connecticut Health Center, is one. "In my clinical experience and based on limited evidence, anticonvulsants, especially divalproex sodium (Depakote), have a significant role in [treating] patients with substance use [disorders]." He asserts that the impact of anticonvulsant medication dierapy is "probably much more significant in bipolar patients with substance use comorbidities," based on his belief diat there are shared "pathophysiological mechanisms involving die GABAergic system."
A recent scholarly review by a group of Italian psychiatrists led by Icro Maremmani noted that there are few studies of the role of anticonvulsants in SUD treatment.1 Of these, most are short-term in duration and therefore offer little insight into long-term effectiveness (e.g., relapses into agitation, impulsivity, and dissatisfaction). The authors believe that anticonvulsants are preferable to antipsychotics or antidepressants in dually diagnosed, substance-abusing patients with bipolar disorder. They argue thar long-term use of antidepressants among such patients may contribute to "switches" into mania along with increased impulsivity and subsequent relapse into substance use. In addition, they argue that the long-term risks of antipsychotic medications outweigh those of anticonvulsants.
For providers considering the value of anticonvulsant medication therapy for "pure" SUDs (e.g., SUDs not associated with other clear psychiatric diagnoses), a handful of studies suggest effectiveness. According to Kamath, "Anticonvulsants have a larger application for [treatment of] alcohol and benzodiazepine use disorders than other substance use disorders. …