Ask the average person how to treat alcoholism, and they’ll probably describe an AA meeting or maybe a 30-day stint in a fancy rehab center. What won’t leap to mind, even for most experts, is medication.
That’s a missed opportunity, according to an analysis of more than 120 research studies that found that prescription medication helps addicts reduce their drinking and the associated harms.
Taken together, the studies involved 22,803 patients who abused alcohol. The bulk of the papers looked at the medications naltrexone or acamprosate. Both made addicts less likely to drink again and reduced the number of “drinking days” when they did relapse.
Studies involving two other medications, topiramate and nalmefene, also reduced drinking but involved a relatively small number of patients. A handful of the studies looked at disulfiram (sold as Antabuse), perhaps the best-known medication used to treat alcoholics. Researchers did not find evidence of a benefit for that drug.
How naltrexone helped this man quit drinking cold turkey
National statistics show that only about a third of alcoholics receive treatment for their addiction. And despite study results, some of which date to the 1990s, only about a third of the patients being treated are currently prescribed medication, according to the paper, which was published this week in the Journal of the American Medical Association. The result: Just 10% of alcoholics get medications that are proven to help them.
An accompanying editorial in the journal put it starkly: “Patients with AUD (Alcohol Abuse Disorder) receive poorer-quality care than patients with any other common chronic condition. Most patients with AUD do not receive treatment, and medications for AUD are particularly underutilized.”
The drugs work by different mechanisms, according to Dr. George Koob, director of the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.
Naltrexone blocks brain receptors that are thought to play a role in the pleasure an addict gets from taking his preferred drug – in this case, alcohol. Acamprosate targets chemicals thought to mediate the addicted brain’s protracted sense of panic or withdrawal in the absence of alcohol. Although both were similarly effective in the larger studies, different patients are likely to respond differently, says Koob, who has studied the neurobiology of addiction.
Some experts have expressed frustration that the drugs are not used more widely. “People just don’t know about it,” said Dr. Raye Litten, associate director of the National Institute on Alcohol Abuse and Alcoholism’s Division of Treatment and Recovery Research. “Many primary care physicians just don’t know about this.”
Both naltrexone and acamprosate are generic products, which reduces financial incentives to market them more widely. Koob says his institute is lobbying doctors and pharmaceutical companies to give the drugs a higher profile while backing research on other anti-addiction medications.
There are practical differences as well. Naltrexone treatment requires only one pill per day, but acamprosate requires two pills taken three times a day. Acamprosate can’t be taken by patients with kidney problems, but naltrexone is dangerous for those with liver damage. Since it blocks opiate receptors, naltrexone also can’t be used by patients taking opiate pain medication.
Dr. Daniel Jonas, one of the studies’ lead authors and a primary care physician in North Carolina, points out that the improvements credited to medication in the studies are in addition to benefits from other treatment; virtually all patients in the studies received counseling or went to AA meetings in addition to taking prescribed medication.
“The general thinking has been that it wouldn’t be appropriate” to simply put people on medication without counseling, but whether that track might work is an unexplored question, Jonas said. If it did, it might make treatment more available to people in areas with few counselors or addiction specialists.
Koob says it’s most important to recognize that effective treatments for addiction do exist.
“In the long term, most people need some kind of behavioral intervention, whether it’s group or individual therapy or mindfulness or religion, if you will,” he said. “But I think medications help you along the way.”
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