Last week I talked about how the latest scientific evidence has proven that alcohol and drug addiction is a chronic brain disease. I also discussed that, as a result of the millions of dollars spent on basic science and clinical research studies on alcohol/drug addiction treatment each year, an increased understanding of the neurobiological mechanisms that maintain substance dependence (addiction) has been developed. This has led us to be smarter about how to combine the appropriate anti-addiction medications with psychosocial treatments to improve the outcomes for alcohol and drug addicted patients.
Finally, I hope that you took a look at the various treatment resources that I mentioned last week, targeted specifically at patients and their families - two primary resources being my book "Healing the Addicted Brain" (www.enterhealth.com/healingtheaddictedbrain), and a patient-friendly website, www.enterhealth.com. These resources help educate and support individuals through this process.
Today I will discuss my ideas on current scientific thinking about pharmacological treatments of addictions, specifically alcoholism and available evidence of their effectiveness.
In spite of the longstanding national focus on drug addiction, it is important to remember that alcoholism is still the most serious substance abuse problem in the U.S. According to the latest statistics, alcoholism is the nation's third leading cause of death, behind only heart disease and cancer. Existing behavioral treatments and programs are not effective for all patients, especially those who do not have the funds or the time to commit to residential treatment or intensive outpatient counseling. There is a significant need for acute medical interventions that can initiate and maintain alcohol abstinence. In addition, relapse to heavy drinking is common and a major challenge to long-term treatment effectiveness.
Different pharmacological agents began to be explored more than 50 years ago to improve the efficacy of existing alcohol treatments, and several medications are currently being used in alcohol rehabilitation. In more recent years, neuroscience has really begun to focus more on understanding the brain in addiction. As a result, more new medications to help treat alcoholism have been developed. I would like to talk about these FDA approved medications for the treatment of alcoholism:
Disulfiram (Antabuse®), a sensitizing or deterrent agent, was approved by the FDA for the treatment of alcoholism in 1951. It has been used as an aid in managing chronic alcoholic patients who want to remain in a state of enforced sobriety so that they can pursue supportive and psychotherapeutic treatment to best advantage. Disulfiram produces sensitivity to alcohol, which results in a highly unpleasant reaction when the patient under treatment ingests even small amounts. It does this by interfering in the metabolic pathway in the liver that breaks down alcohol, resulting in an accumulation of acetaldehyde in the blood. This toxic by-product of normal alcohol metabolism produces a complex of highly unpleasant symptoms, including intense nausea. The intensity of the reaction varies with the individual but is generally proportional to the amount of disulfiram and alcohol ingested.
In my addiction treatment practice, I consider disulfiram only as a third or fourth choice to help my alcoholic patients. Although some small-scale studies have shown it to be superior to placebo, in the largest controlled trial, a multi-center, randomized VA study, disulfiram failed to demonstrate greater efficacy than placebo. However, it does have a valid place as an integral part of certain recovery programs. It is obviously more effective when its compliance can be verified, most frequently via direct daily observation of ingestion.
Renewed interest in pharmacological treatments for alcoholism led to the FDA approval of an opioid antagonist, naltrexone (Trexan® or Revia®), in 1994 for the treatment of alcohol dependence. Unlike disulfiram, naltrexone is not primarily a deterrent to alcohol use - it does not make use sick when you drink alcohol. Rather, it is thought to reduce alcohol consumption by reducing or even completely blocking the reward (the high or the euphoria) from drinking alcohol, significantly reducing cravings for alcohol, and decreasing the "priming effect" of the first drink for a relapse or slip. Clinical study results for naltrexone have been relatively compelling in regard to its effectiveness most of the time, supporting its effectiveness, though sometimes not.
However, more recently, science has produced a very exciting new anti-addiction IM (stands for intramuscular - meaning in "shot" form) medication for the treatment of alcohol dependence - called VivitrolTM - a once-monthly extended-release, injected version of naltrexone (the exact same medication that I mentioned above,) which was recently approved by the FDA in mid-2006. This monthly "shot" of extended-release naltrexone lasts for a full 30 days with each injection and has significantly revolutionized the recovery from alcoholism, by removing the need for daily decision making about compliance, thereby drastically reducing or completely stopping alcohol use for alcoholics receiving the medication and attending active treatment programs.
Acamprosate (Campral®) has been used in Europe for the treatment of alcohol dependence since the late 1980s. It was not available in the U.S. until ultimately approved by the FDA in 2004. Although the precise mechanism of action or "cellular target" of acamprosate is unknown, it appears to decrease cravings primarily by restoring the balance in certain neurotransmitter pathways (most likely GABA and Glutamate) that have become altered by chronic alcohol consumption. Fourteen out of 16 controlled clinical trials in European countries have demonstrated evidence for its effectiveness, showing that acamprosate-treated patients have a significantly greater rate of treatment completion, time to first drink, and abstinence rates than patients treated with placebo.
In my clinical practice, with most alcoholics, I have found it helpful to prescribe both Vivitrol and Campral simultaneously. As they have different mechanisms of action, they are rather synergistic in their impact on this devastating chronic medical illness (similar to when a doctor might prescribe 2 different medications for severe high blood pressure - where each one reduces your blood pressure in a different way.) I would recommend that all physicians strongly consider using at least Vivitrol for all of their alcoholic patients, in concert with strongly recommending and encouraging participation in local intensive outpatient treatment and twelve-step programs.
Even with all of the great scientific breakthroughs discussed above for the treatment of alcoholism, scientists are not stopping in their search for even better and more effective anti-addition medications and treatments. Although not yet FDA approved for alcoholism, other promising candidates currently being studied include Topamax, Baclofen, Zofran and Prometa. (Look for much more detailed information regarding Vivitrol, Campral and Antabuse in my book, "Healing the Addicted Brain" or visit www.enterhealth.com/healingtheaddictedbrain)
Hopefully, today's entry can give you a better understanding of the fact that traditionally, physicians have not had much in their little black bags to offer to their patients struggling to remain sober. Fortunately, new scientific advances have made possible a new generation of anti-addiction medications for alcoholism that offer unprecedented possibilities for treatment and recovery. Newly approved medications, when combined with traditional treatment programs, make it possible for people to stay on their "no high" medicines, reduce their cravings, and help rebalance the brain's biochemistry.
- Dr. Urschel