Modafinil with CBT may improve drug rehab for gay men with HIV

Methamphetamine use has been linked to increased risk of human immunodeficiency virus (HIV) among gay men. Methamphetamine is a highly addictive stimulant that may lower inhibitions, increase sexual arousal, and lead to risky sexual behavior such as unprotected sex. Further, methamphetamine may be injected, and needle-sharing is also a risk factor for HIV.  These two epidemics have spread concurrently among gay men. There is a need for specialized approaches for addiction treatment and drug rehab for gay men with HIV, if such approaches could be developed.

Researchers from the New York State Psychiatric Institute and Columbia University evaluated the efficacy of modafinil plus cognitive behavioral therapy as a treatment for methamphetamine dependence among gay men with HIV (McElhiney et. al., 2009). Modafinil (trade name are Provigil, Alertec, Modavigil, Modalert) is approved by the U.S. FDA for the treatment of narcolepsy, sleep disorders, and excessive sleepiness. Modafinil promotes wakefulness by increasing the release of the catecholamines norepinephrine and dopamine from the synaptic terminals and elevating hypothalamic histamine levels. Since modafinil increases histamine levels as well as catecholamine levels, it has lower abuse potential as compared to classic amphetamine-like stimulant drugs, because of a different synergistic effect on the brain’s reward system. Previous research has suggested that modafinil may be an effective treatment for cocaine dependence.

Cognitive behavioral therapy (CBT) is used as a treatment of choice for many psychological disorders. For drug using or drug dependent individuals CBT teaches a range of coping skills and relapse prevention strategies. CBT participants learn about their cravings and how to cope with them, how to avoid triggers (the people, places and things linked to their drug of choice) and how to cope with feelings that may trigger relapse. Additionally, participants in CBT treatment may also learn how the basic CBT approach can be applied to other issues in their lives, such as depression, anxiety or rage and hostility.

In the McElhiney et. al. study, modafinil was administered for 12 weeks followed by a 4-week placebo phase. CBT was conducted for 18 sessions during the study, which lasted for a total of 16 weeks. Results were measured by self-reported use as well as by urine screens. A response was defined as a reduction by more than 50 percent in days used. Thirteen participants enrolled in the trial, and ten participants completed it. Two dropped out of the trial because of side effects. Six out of ten participants who finished the trial reduced their methamphetamine use by more than 50 percent. This preliminary study showed that modafinil combined with cognitive behavioral therapy produced good retention in methamphetamine addiction treatment among gay men with HIV. The study supports further research of modafinil plus CBT in stimulant drug addiction.

The use of modafinil for addiction treatment may be controversial because modafinil appears to provide a milder version of the effect methamphetamine users are seeking from methamphetamine itself. Will modafinil users then become addicted to modafinil? Assuming that at least some will become addicted, further research will be needed to determine whether this secondary addiction is a sufficient improvement over amphetamine addiction to make modafinil (combined with cognitive behavior therapy or another psychosocial treatment) a treatment worth considering. Even if long term modafinil maintenance (which would be similar to methadone or Suboxone maintenance) were not used, modafinil might be used early in drug rehab, as part of a stepped care approach to addiction recovery.

References

Kampman KM, Lynch KG, Pettinati HM, O’Brien CP. A double-blind, placebo-controlled trial of modafinil for cocaine dependence. Neuropsychopharmacology. 2005; 30(12): 2299-2300.
 
McElhiney MC, Rabkin JG, Rabkin R, Nunes EV. Provigil (Modafinil) plus cognitive behavioral therapy for methamphetamine use in HIV+ gay men: a pilot study. American Journal of Drug and Alcohol Abuse. 2009; (35)1: 34-37.