Bruce BassiThe treatment for alcohol use disorder includes individual therapy, group therapy, and medication options. Alcoholism is a disease process that must be treated similar to a medical and mental health disorders. Although this article focuses on medication treatment options, individual and group therapy are very helpful and have scientific evidence to support them.
KEY TAKEAWAYS
- Acamprosate should be favored over naltrexone for individuals with liver disease and those with concern for drug interactions.
- Acamprosate can be taken when an individual is on opioids. Naltrexone cannot.
- In treatment for alcohol use disorders, acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving.
- Individuals with renal disease should adjust or stop acamprosate; those with liver disease should not take naltrexone.
- Patients should also be encouraged to maintain involvement in counseling and 12-step programming while exploring medication options.
Most physicians first utilize the FDA approved medications to treat alcoholism. However, there are other medication options that have gathered evidence to treat alcoholism, but have never been submitted to the FDA officially for approval for this indication.
The three main FDA approved medication options are: naltrexone (brand name ReVia), acamprosate (brand name Campral), and disulfiram (brand name Antabuse).
What is Naltrexone?
Naltrexone works primarily as an opioid blocker. It is not addictive or habit forming. Its mechanism of blocking opioid receptors helps blunt one of the overactive pathways in addiction that reinforces the binge/intoxication behavior. Naltrexone reduces the urge to consume alcohol through suppression of alcohol-mediated beta endorphine stimulation of dopamine in the nucleus accumbens and also through reduction of the beta-endorphine disinhibition of tonic inhibition of dopamine cells by GABA neurons in the ventral tegmental area. Naltrexone blunts the effects of both endogenous and exogenous opioids, and therefore caution must be used if concurrently taking opioids. It blunts the euphoric effects of alcohol, and individuals often describe that drinking alcohol is just not the same anymore. As a result, it may make certain people feel more depressed. This is not seen universally, but should be taken with caution for an individual struggling with depression concurrently. Naltrexone has been shown to increase the number of days of abstinence, and also reduce days of heavy drinking.
What are potential side effects of Naltrexone?
The most common side effect to naltrexone is nausea. Other common side effects are headaches, and fatigue, and less commonly diarrhea. Individuals should wait at least 7 days after their last use of other opioids (and 10+ days for long acting opioids) before taking it, since it could precipitate withdrawal symptoms. A clinician will discuss with you any current or past liver problems, history of bleeding disorders, plan to become pregnant, or plan to use any opioid-containing medications for pain, cough, colds, or diarrhea. The GI side effects are common and are dose dependent, so patients with GI symptoms should try utilizing a lower dosage.
What is Vivitrol?
An extended release version of naltrexone is available in the form of Vivitrol, which is 380 mg of naltrexone given once per month delivered via a gluteal injection. Vivitrol is indicated for patients who can refrain from drinking for several days before treatment begins. Interestingly, many individuals have described finding more effectiveness with Vivitrol than oral naltrexone.
What is the Sinclair Method?
Some individuals utilize naltrexone to treat problematic drinking with a method developed by Dr. John D. Sinclair. You would take naltrexone about 1-2 hours prior to drinking alcohol to potentially reduce the buzz or pleasure from alcohol. For some individuals, alcohol doesn’t help if the patient is told to remain abstinent. Instead, they take it prior to drinking to reduce the amount they drink and reduce the positive reinforcement from drinking.
Acamprosate
Acamprosate is a medication that is approved to help treat relapse of alcohol dependence. It modulates the N-methyl-d-aspartic acid (NMDA) receptor transmission and may have indirect effects on γ-aminobutyric acid type A (GABA Type A) receptor transmission. It decreases brain glutamate and increases beta-endorphines. Its effects are subtle and relate to reducing anxiety, insomnia. It would take at least 8 days of regular use before it is effective. It is found to increase the chance of abstinence by about 15% according to a 2010 Cochrane review. Acamprosate may provide some benefit of neuroprotection in the withdrawal state withdrawal, as evidence has demonstrated that it decreased the hyperglutamatergic state associated with withdrawal.
What are side effects of acamprosate?
Acamprosate is generally well-tolerated and most list diarrhea as the main side effect and is self-limited.
Disulfiram
Disulfiram (brand name Antabuse), is a medication used in the treatment of alcohol use disorders by a sick reaction upon ingestion of alcohol. It is used as a deterrent to drinking via negative reinforcement, to try to reduce the immediate unwanted effects of alcohol. When alcohol is consumed it is converted into acetaldehyde and then into acetic acid. Disulfiram blocks the conversion from acetaldehyde to acetic acid, thus resulting in an upsurge of acetaldehyde, which is toxic and causes an individual to become ill. Disulfiram is dispersed in tablet form and taken orally one time per day and comes in 250 mg or 500 mg tablets. The maximum recommended daily dosage is 500 mg. Disulfiram can also be used at lower dosages to treat cocaine addiction. An individual should have abstained from alcohol for at least 12 hours.
What are potential side-effects of disulfiram?
Commonly experienced side effects are: headache, sleepiness, tiredness, and change in taste (typically metallic taste). Patients receiving metronidazole, or alcohol-containing preparations (sauces, cough mixtures, vinegar) should not receive disulfiram and must be educated prior to taking to avoid a disulfiram-alcohol reaction.
What are non-FDA approved medications for treating alcohol use disorder?
- Gabapentin – There is a randomized control trial published in JAMA in 2014 that showed 1800 mg per day dosage in particular was effective in improving abstinence, and heavy drinking days.
- Topiramate – There is study published in JAMA in 2007 that found up to 300 mg topiramate decreased heavy drinking days. Side effects included paresthesias, taste perversion, trouble concentrating.
- Baclofen – To date there have been 15 randomized controlled trials investigating the use of baclofen in AUD; three using doses over 100 mg/day. Two additional RCTs have been completed but have not yet been published. Most trials used fixed dosing of 30–80 mg/day. particularly advantageous in those with liver disease, due to its limited hepatic metabolism and safe profile in this population
- Spironolactone – There was a recent retrospective review study in the Journal of Molecular Psychiatry looking at the use of 50+ mg of spironolactone for treating alcohol use disorder and was found to reduce alcohol consumption.
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