Using Medicine to Treat Alcoholism: Where We Are, Where We’re Going
A growing list of pharmacological options gives addiction recovery a boost
For as long as people have been drinking alcohol, there have attempts to use medicines to help them stop. Today, physicians who specialize in addiction treatment (American Society of Addiction Medicine, American Association of Addiction Psychiatry) use a variety of pharmacological approaches to help patients control their alcohol use, and the list of possibilities is growing rapidly. When used along with social support and psychological and behavioral interventions, medication can sometimes make the difference in reclaiming one’s life.
If you’re curious about what medicine might do for you or someone you love, here’s a look at treatments that are available now and those that might be just around the corner.
Back in the early part of the 20th century, a curious effect was noticed among those who worked making auto tires: They had severe reactions when they drank alcohol. In 1949, a chemical used in that production process, tetraethylthiuram disulfide, became the basis of the first medication approved for the treatment of alcohol — disulfiram, also known as Antabuse.
Alcohol is broken down by the body in two steps. Disulfiram works by blocking the enzyme required for the second step. Stopping the metabolism of alcohol at this point results in a host of unpleasant effects whenever alcohol is consumed, including severe nausea, sweating, neck and chest pain, blurred vision, headache, rapid heartbeat, confusion and dizziness. The idea behind taking disulfiram is that if you drink, you will fall violently ill instead of feeling good. Knowing how miserable you’ll be if you drink discourages someone from taking the first drop.
For some, this works and truly transforms their lives. They drink less often and when they do, they limit their intake (out of fear of the reaction). They may eventually become completely abstinent. In some cases the urge to drink is so great, patients “cheat” and eventually stop taking the medicine altogether. Others discover that even though they are taking disulfiram, the negative reactions don’t occur or are not severe enough to stop them from drinking.
Although many clinicians have abandoned disulfiram in favor of safer and potentially more effective treatments, there remains a committed base that continues to use it, most often in monitored situations such as treatment clinics, or when a spouse or friend makes sure they are taking the drug regularly and behaving responsibly.
Naltrexone has been around for decades as a treatment for opioid addiction and was approved as a treatment for alcoholism in the 1990s after it was found to decrease the number of times when a person drinks heavily. In simple terms, naltrexone, sold as ReVia, works by blocking alcohol’s effect on the pleasure receptors in the brain. As a result, it can limit the “buzz” or high felt from drinking, diminish cravings, and help to break the cycle of wanting to drink more and more.
It has some drawbacks that have limited its widespread adoption. Its effects, both in the short and long term, are limited since people often struggle to comply with taking a pill every day that they know will eliminate the reward they get from drinking. A long-acting injectable version that is taken once a month, marketed as Vivitrol, has helped with compliance, but it’s expensive and not all insurers cover the cost.
Approved for use in the U.S. in 2004, acamprosate, also known by its brand name Campral, is thought to help normalize brain activity disrupted by alcohol. Taking acamprosate decreases the distressing mood changes that occur with attempted sobriety (such as anxiety, restlessness and insomnia) that often lead to relapse.
Randomized controlled trials in Europe showed increased continuous abstinence rates during six months of treatment with acamprosate. Curiously, though, the results weren’t duplicated in two large U.S. trials. In fact, no significant difference was found between acamprosate and placebos.
No one knows what accounts for the difference in the results among these studies. Some scientists believe that genetic differences may be involved, or that alcoholics in the U.S. are more likely to abuse other drugs at the time. As a result, European physicians are more likely to prescribe acamprosate for alcoholism than their U.S. counterparts.
Nalmefene has a lot in common chemically with naltrexone. It also blocks the opiate receptors in the brain involved in the pleasurable effects of alcohol. The big difference is in how the patient is instructed to use the drug. With naltrexone, the client is told to take the same dose every day. Nalmefene, on the other hand, is intended to be taken on days when the person may be planning to have drinks, at least two hours ahead of time. The idea is that when the person takes nalmafene and then drinks, they will not enjoy it. Since alcohol has become less pleasurable, they will crave it less and eventually lose the urge to have it. From a learning psychology perspective, the habit is extinguished.
The great appeal here is that it only needs to be taken when needed. There’s considerable interest in this approach in Europe, although compelling evidence of nalmefene’s effectiveness is still lacking. The U.S. has yet to approve it as a treatment for problem drinking.
Two European Union countries recently approved this drug, also known as GHB, as a substitution therapy for alcohol.
What that means is it is used much as methadone is for opioid addiction: Patients take sodium oxybate on a schedule instead of drinking alcohol and because they have some neurochemical effects in common, the person can avoid withdrawal and cravings. As a result, they can get on with their life without feeling so bad they relapse. Like alcohol, sodium oxybate can spark certain levels of euphoria and can be addictive — in fact, it is often diverted as a party drug. That means prescribing must be tightly controlled and medically monitored if used in the treatment of alcoholism. Even so, there have been relatively few instances reported where patients who were being treated for alcoholism with oxybate also abused the drug.
Although sodium oxybate is approved in the U.S. for certain sleep disorders, it is tightly regulated and doctors here cannot prescribe it for alcoholism.
Also on the radar are several other drugs that are widely available but have not yet been approved in the U.S. for the treatment of problem drinking. In some cases, physicians are already using them for this purpose because a lot is known about their long-term safety. Among these drugs are:
- Gabapentin. Currently approved for the treatment of epileptic seizures and neuropathic pain, this drug has been shown in research to reduce the number of heavy drinking days as well as the severity of symptoms that can prompt relapse, such as insomnia, cravings and feelings of unease.
- Topiramate (Topamax). It’s another drug approved for seizures but not yet OK’d for the treatment of alcoholism. Like acamprosate, it is thought to help limit the distressing changes in mood that can make relapse more likely.
- Varenicline. It’s currently sold under the brand names Chantix and Champix to help those trying to overcome an addiction to nicotine. The thought is its ability to block reward receptors in the brain may work with alcohol as well.
Considered together, the growing options help brighten the outlook for those struggling with alcohol abuse, who can now expect to have access to more tools than ever from their treatment providers.
Key to remember in the changing landscape, however, is that none of the pharmacological choices is an answer by itself. Studies related to each medicine emphasize that getting to the psychological roots of alcohol use and teaching ways to challenge negative thinking and deal with the cues that so often spark relapse remain a crucial part of the recovery picture. Still, for those working to reclaim their power over alcohol, medication can sometimes provide the missing piece of the puzzle.
Sack, D. (2016). Using Medicine to Treat Alcoholism: Where We Are, Where We’re Going. Psych Central. Retrieved on February 20, 2018, from https://blogs.psychcentral.com/addiction-recovery/2016/04/using-medicine-to-treat-alcoholism-where-we-are-where-were-going/