As millions of Americans battle alcohol abuse problems each year, public health officials suggest that two often overlooked medications might offer relief to some.
More than 18 million people abuse or are dependent on alcohol, yet a key study funded by the federal government reported last year that only 20% will ever receive treatment of any kind. In fact, just slightly more than 1 million seek any type of formal help, ranging from a meeting with a counselor or a doctor to entering a specialized treatment program.
Acknowledging that for many people peer-support programs, such as Alcoholics Anonymous, work well, federal officials also want to encourage physicians to be more involved in identifying and treating alcohol problems and are seeking to increase awareness of drug treatments.
“We want people to understand we think AA is wonderful, but there are other options,” said George Koob, the director of the National Institute of Alcohol Abuse and Alcoholism, a part of the federal National Institutes of Health. “Let a thousand flowers bloom, anything helps.”
The NIAAA has developed a branch dedicated to development of medications and is supporting trials of drugs to give patients and doctors more options.
NIAAA and the Substance Abuse and Mental Health Services Administration also asked a panel of outside experts to report last summer on drug options.
“Current evidence shows that medications are underused in the treatment of alcohol use disorder, including alcohol abuse and dependence,” the panel reported. It noted that although public health officials and the American Medical Association say dependence on alcohol is a medical problem, there continues to be “considerable resistance” among doctors to this approach.
It is still rare for a person struggling with an alcohol use disorder to even hear that medication therapy exists. That partly reflects the overwhelming tradition to treat alcohol abuse through 12-step programs. It’s also a byproduct of limited promotion by the drugs’ manufacturers and confusion among doctors about how to use them.
“They’re very safe medications,” said Koob. “And they’ve shown efficacy.”
A 2014 analysis in the Journal of the American Medical Association of past studies found that both drugs “were associated with reduction in return to drinking.”
For one North Carolina woman eager to get sober, naltrexone provided that help. Dede said she went to hundreds of Alcoholics Anonymous meetings. She spent time in two different rehabilitation facilities, one of which cost her $30,000 out of pocket. But she still struggled.
“The self-loathing was the worst thing about it,” she said. “I hated myself as an alcoholic, but I could not stop.”
Eight years ago she decided to try yet another approach — meetings for people who had drinking problems with counselors at the University of North Carolina at Chapel Hill. That’s where she first heard about naltrexone.
One of the counselors mentioned Dr. James C Garbutt, a professor of psychiatry who treats patients with alcohol use disorders, often using naltrexone. She asked to get an appointment with him but was told it would take weeks to fit her in. She wouldn’t wait that long. Instead, she showed up in the doctor’s waiting room and stayed until he was able to see her.
“I begged. I really begged to get to see him,” she explained.
With the help of naltrexone and one-on-one counseling, Dede said she has consumed no more than two sips of wine since that visit. She agreed to be interviewed on the condition that Kaiser Health News use only her nickname because she has tried to keep her alcohol abuse private.
A third drug is also available, but it does not work against alcohol cravings. Disulfiram, also known by the brand name Antabuse, makes people violently ill when they consume alcohol. It has been found to be less effective in helping stem alcohol abuse than the other two drugs.
Naltrexone, which is also used to help treat opiate addiction, comes in both an oral and injectable form and has few side effects. It was approved for use in alcohol addiction in 1994. Acamprosate was approved in 2004 to treat only alcohol problems. It comes as a tablet.
When naltrexone came on the market, sales teams had trouble explaining how the drug worked differently than Antabuse to the non-physician administrators who made treatment decisions in addiction clinics, addiction experts said. Many misunderstood how and for whom the drug worked. Some of that persists today.
“They got three years” of market exclusivity, said Dr. Henry Kranzler, director for the Center for Studies of Addiction at the University of Pennsylvania. “Three years is not a very long time to make a market where there really isn’t much of a market and they didn’t.” The company discontinued its effort to market the drug in 1997.
Many of the same marketing problems also persist for acamprosate.
Some of naltrexone’s history in opioid treatment also hurt its image. The drug blocks the effects of opioid receptors in the brain. So any patients who took it without having completely detoxed from opiates were launched into agonizing withdrawal. The label urged doctors only to prescribe the medication to patients that had already been opiate-free for at least 10 days.
But it doesn’t have the same effect on patients with alcohol use disorders. A patient who drinks while taking naltrexone will get drunk — and not have those withdrawal symptoms. Yet, when the drug was approved for alcohol use disorders in 1994, the label still stated patients should be completely sober before using naltrexone.
Often, care providers consider complete abstinence the only successful outcome of treatment, yet patients who drink while taking naltrexone get drunk without the opioid-induced reward to reinforce the behavior. The absence of this reward makes drinking less appealing in the future.
Garbutt, who was on the expert panel last year, encourages complete abstinence for his patients, but also supports patients who would rather set a goal of harm reduction.
“If we can reduce your intake 80 percent and reduce your heavy drinking days a lot, that’s also very positive,” he said. “Some people just aren’t ready. The idea of sobriety is just too big of a concept for them to wrap their head around.” And naltrexone can help patients with either of these goals — abstinence or reduced drinking.
In fact, explained Garbutt, while naltrexone does help patients remain abstinent, “the effect of reducing heavy drinking is the most prominent effect of naltrexone.”
Top image: Assorted liquor bottles. Photo by Steven Darby.