Medication Assisted Treatment For Alcohol Dependence

By Julie A. Kmiec, DO Statistics about alcohol use From 2001 to 2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducted the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), one of the largest surveys of its kind ever performed. NESARC estimated that 65% of the U.S. population drinks alcohol and that about 13% either abuse alcohol or are dependent on alcohol. Regarding binge drinking (having more than 5 drinks on one occasion if male or more than 4 drinks on one occasion if female), 2009 data from the Center for Disease Control showed that more men (21.1%) binge drank than women (10.6%). The NESARC study also looked at the prevalence of alcohol and other drug use and found 8.5% of adults met criteria for an alcohol use disorder, 2% of adults met criteria for a drug use disorder, and 1.1% met criteria for both disorders. Young adults (ages 18-24 years) had the highest percentage of co-occurring drug and alcohol use disorders (4.6%). Compared with women, men were more likely to have alcohol, drug, and co-occurring disorders. People who smoke cigarettes are much more likely to drink alcohol, and people who drink alcohol are much more likely to smoke, according to NESARC data. People who are dependent on alcohol are three times more likely to be smokers, and people who are dependent on nicotine are four times more likely to be dependent on alcohol. Alcohol use and your health NESARC data also showed people with alcohol or co-occurring alcohol and drug use disorders are more likely to have psychiatric disorders such as personality, mood, and anxiety disorders. They are also more likely to attempt suicide. Alcohol consumption may contribute to the risk for developing different cancers, including cancers of the mouth, throat, esophagus, liver, colon, and breast. Heavy alcohol use may also result in inflammation of the esophagus, stomach, and pancreas, gastrointestinal bleeding, fatty liver, alcoholic hepatitis, and cirrhosis of the liver. People with viral hepatitis who use alcohol may have worsening of liver function. Excessive drinking may cause neurological problems, including memory loss or dementia, stroke, and neuropathy, as well as contribute to psychiatric problems such as depression, anxiety, and insomnia. Heavy alcohol use may also contribute to cardiovascular problems, including heart attack, cardiomyopathy (inflammation and poor functioning of the heart muscle), atrial fibrillation (irregular heart rhythm), and high blood pressure. Regarding reproductive health, excessive drinking may disrupt a woman’s menstrual cycle, increase the risk of infertility, miscarriage, still birth, and premature delivery, and cause fetal alcohol syndrome. In men, excessive use of alcohol can interfere with testicular function and hormone production, resulting in impotence, infertility, and reduction of secondary sex characteristics, such as facial and chest hair. Lastly, people are more likely to act impulsively when drinking and this results in motor vehicle accidents, physical and sexual assault, and suicide. It is important to add that since so many people who are addicted to alcohol smoke cigarettes, they are also at risk for tobacco-related health problems including cancer, lung disease, and heart disease. In fact, statistics show that people with alcohol dependence are more likely to die from tobacco-related illness than complications from alcohol use. How someone becomes addicted to alcohol Under normal conditions, the brain’s balance of chemical messengers, called neurotransmitters, allows the body and brain to function unimpaired. Alcohol is able to penetrate the blood brain barrier and upset this balance. The brain has both inhibitory neurotransmitters and excitatory neurotransmitters. Inhibitory neurotransmitters delay or stop nerve signals. Excitatory neurotransmitters speed up nerve signals. Alcohol slows signal transmission in the brain and this contributes to sleepiness people feel when drinking. If someone drinks alcohol on a regular basis, the brain tries to compensate for alcohol’s slowing effects by increasing the activity of the excitatory neurotransmitters and the number of excitatory receptors. Thus, the brain seeks to restore itself to a normal state in the presence of alcohol. Over time, the brain adapts to alcohol’s presence and someone who drinks regularly will respond to alcohol differently than someone who rarely drinks alcohol. These changes are called tolerance and dependence. Tolerance means that it takes a larger amount of alcohol to achieve the same level of response achieved when first used. Dependence means the neurons have adapted to the repeated alcohol exposure and only function normally in the presence of alcohol. What happens when you try to quit drinking? If someone suddenly stops drinking alcohol after a long period of chronic use, the brain has to adapt to not having alcohol and a person experiences alcohol withdrawal. Symptoms of mild to moderate alcohol withdrawal include sweating, increased heart rate and blood pressure, anxiety, nausea, flushed face, and restlessness. Alcohol withdrawal can be severe, resulting in seizures, hallucinations, delirium tremens, and death. People often resume drinking to avoid experiencing symptoms of withdrawal. Even after acute withdrawal symptoms have resolved, people may experience anxiety and trouble sleeping which may contribute to relapse. Treatment for alcohol dependence Some people who notice they have a problem drinking are able to stop drinking on their own. Others try to stop drinking by attending mutual support meetings, such as Alcoholics Anonymous (AA). Some people get treatment for alcohol dependence by attending counseling or alcohol rehabilitation programs. In addition to AA and psychosocial treatments, there are three medications that are approved by the Food and Drug Administration for treatment of alcohol dependence that may aid in your recovery. These medications are acamprosate, naltrexone, and disulfiram and they are described on the pages that follow. Acamprosate (Campral®) How it works It is thought that acamprosate helps modulate and normalize alcohol-related changes in brain activity, thereby reducing symptoms of prolonged withdrawal, such as anxiety, restlessness, and disturbances in sleep and mood, which may trigger a relapse to drinking. Acamprosate has been found to be helpful in reducing number of drinking days, increasing complete abstinence, and lengthening time to relapse. Possible adverse effects Headache, nausea, diarrhea, intestinal cramps, flatulence, increased or decreased sex drive, insomnia, dizziness,

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  • Naltrexone is appropriate for people with intense alcohol cravings. Also, its opiate blocking properties make it a good treatment for people who have both alcohol and opiate use disorders.
  • People who are prescribed opiate pain medications should not take naltrexone.
  • People with liver or kidney disease may take naltrexone but their liver and kidney function should be monitored carefully.

When and how you should take it Naltrexone comes in both a tablet (Revia®) and an injectable form (Vivitrol®). The tablet is taken once daily and you should take it at the same time each day. The shot is given once a month. If you have a slip or relapse, you should continue to take naltrexone. You should wait 3-7 days after your last drink before you start naltrexone. If you also use opiates, you should be opiate-free for 7-10 days before starting naltrexone otherwise you may experience opiate withdrawal. Note Due to opiate receptor blockade, narcotic pain medications may not be effective if prescribed. Larger doses of opiates may need to be used to treat pain in an emergency until naltrexone is out of the system. If you are scheduled to have a procedure after which you will be prescribed narcotic pain medication, your doctor will probably instruct you to stop taking naltrexone for about 3 days prior to the procedure. Be sure to tell all of your doctors that you are prescribed naltrexone. You may also choose to wear a medical alert bracelet stating you are taking naltrexone in case of an emergency. Disulfiram (Antabuse®) How it works Disulfiram works by inhibiting an enzyme that helps metabolize alcohol. If people drink while taking this medication they will have a build-up of an alcohol by-product that causes them to get sick. People who drink while taking disulfiram tend to experience a disulfiram-alcohol reaction which includes: flushing, sweating, nausea, vomiting, dehydration, increased heart rate. The reaction may be severe and cause trouble breathing, irregular heartbeat, heart attack, heart failure, seizures, unconsciousness, death. These adverse effects tend to start 10-30 minutes after alcohol is ingested. The effect is generally in proportion to the amount of alcohol ingested and the dose of disulfiram. The reaction may occur for up to 14 days after the last dose of disulfiram. Although disulfiram may not reduce the urge to drink alcohol, the expectation of a severe reaction if one drinks alcohol may increase motivation to not drink. It has been found to be helpful in reducing number of drinking days. Possible adverse effects Rash or acne, drowsiness, fatigue, headache, impotence, metallic aftertaste, neuropathy, liver inflammation or failure, and psychosis. Who may take it People who are motivated for treatment and are committed to total abstinence may do well on this medication. People who may impulsively drink are not good candidates for disulfiram. People with severe heart disease should not take this medication. People with liver disease, diabetes, hypothyroidism, epilepsy, and kidney disease may possibly take this medication but need to be monitored closely by a physician. When and how you should take it Disulfiram is taken once a day. You should not take it until alcohol is out of your system otherwise you may experience the disulfiram-alcohol reaction. You should not use alcohol containing products while taking disulfiram such as mouthwash, cough syrups, and aftershaves. Also, some vapors in paint, paint thinners, and varnishes may cause the disulfiram-alcohol reaction.

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