While behavioral treatments and support groups are the mainstay of treatment for alcohol abuse problems, there are medications that can be helpful as well.
Naltrexone is an opiate antagonist that is used for the treatment of alcohol dependence. Research shows that it is particularly useful in decreasing heavy drinking. It is found to be more helpful in people who are still drinking versus people who are abstaining already from alcohol. It works to extinguish drinking by removing the positive reinforcement effects to alcohol on the brain. Multiple studies have demonstrated its efficacy in reducing the frequency and severity of relapses. The multi-center COMBINE study showed the usefulness of naltrexone in the primary care setting.
A typical dose of oral naltrexone is 50mg/day (dosed qday or bid). A once-monthly, extended-release injectable formulation (Vivitrol) is available as well and is typically dosed at 380 mg qmonth. Common side effects include diarrhea and abdominal cramping. There is an FDA black box warning about the potential for liver damage, but further research has shown that this is a rare side effect and occurred only in patients who were given a higher-than-recommended dose. Still, some physicians elect to check baseline LFTs and monitor them periodically. It is important to avoid using opiate medications while taking naltrexone.
Acamprosate (Campral) is approved by the FDA for treatment for alcohol dependence with other supportive therapies. Studies have shown it to be helpful in both reduced consumption of as well as maintaining abstinence from alcohol. Its mechanism of action is still under study. Common side effects include diarrhea, headaches, insomnia and impotence. Less common but more serious side effects include irregular heart rate and effects on blood pressure. Acamprosate is cleared through the kidneys, so kidney function should be assessed prior to using the medication.
Disulfiram (Antabuse) works by producing an acute sensitivity to alcohol consumption by inhibiting acetaldehyde dehydrogenase. With disulfiram on board, 5-10 minutes after alcohol consumption, the patient will experience “hangover” symptoms for the next 30 minutes-several hours. These symptoms include flushing of the skin, accelerated heart rate, shortness of breath, nausea, vomiting, headache and mental confusion.
Typically the regimen is initiated by prescribing 500mg qday x 1-2weeks then the maintenance dose is 125-500mg qday until the patient has fully abstained from alcohol. There is no tolerance to disulfiram – the longer it is taken, the stronger its effects. The main drawback is that the patient has to be motivated to take the medication consistently.
This medication does not decrease craving for alcohol, so it is important that it be used in conjunction with supportive therapy and motivational interviewing. Common side effects include headache and metallic taste in mouth. It should not be taken within 12 hours of drinking alcohol and its effects can last for up to 2 weeks.
Gabapentin (Neurontin) was discussed in part 1 of this series as a treatment for prevention of withdrawal seizures but can also be used to maintain abstinence and prevent relapse.
All these medications work best in the context of psychosocial treatment. At least three forms of psychosocial therapy have been shown to be effective at treating alcoholism, with roughly similar success rates. These include:
- Cognitive behavioral therapy, a form of psychotherapy focusing on identifying and modifying negative thoughts and thought patterns.
- 12-step facilitation, in which patients are encouraged to enter 12-step programs such as, Alcoholics Anonymous.
- Motivational enhancement therapy, a patient-centered approach in which counselors try to get patients to think about and express their motivations for change and to develop a personal plan that can help them make the necessary changes.