Alcoholism

Description

Medications

Opioid antagonists are drugs that reduce the intoxicating effects of alcohol and the urge to drink. The two most often used are naltrexone and nalmefene. These agents are useful for helping people who are still drinking although they have no effect for people who are already abstinent.

Naltrexone. Naltrexone (ReVia) is approved for the treatment of alcoholism and is effective for reducing alcohol dependence in the short term for people with low to moderate alcohol dependency. For best results, it should be used with cognitive behavioral therapy but it may also help many alcohol-dependent people without access to psychologic support. The drug does not work in all patients. A 2003 study suggested that people with a specific genetic variant called ASn40 respond better to the drug than those without the gene. The gene regulates receptors that affect the response to opioids. Another study reported that it offered no advantages for men with chronic, severe alcohol dependence, particularly if they have no social support. More research is needed to clarify its effects and also to determine it improves quality of life.

Taking the drug consistently as prescribed by the doctor is very important for its success. One study suggested that it otherwise may be safely and most effectively administered as follows:

• Psychotherapeutic treatments should be given concurrently.
• Only patients who are still drinking should take naltrexone. (The drug is not useful in patients who are already abstinent.)
• Sober patients should take naltrexone only when they anticipate a drinking relapse.

However, some experts believe it is safe and effective to use naltrexone indefinitely. The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses can cause liver damage. The drug should not be administered to anyone who has used narcotics within a week to 10 days.

Nalmefene. Nalmefene blocks more opioid receptors than naltrexone does, and it may have less of an adverse effect on the liver. It is still under investigation, and like naltrexone, nalmefene does not seem to improve abstinence rates.

Aversion Medications (Disulfiram)

Some drugs have properties that interact with alcohol to produce distressing side effects. Disulfiram (Antabuse) causes flushing, headache, nausea, and vomiting if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and may last from half an hour to two hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for one to two weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. Compliance is also low with this agent. Studies have not shown the use of disulfiram to have any effect on staying abstinent, although it does reduce the frequency of drinking. The drug is more effective if patients have family or social support, including AA "buddies," who are close by and vigilant to ensure that they take it. (Such support, however, probably improves the effectiveness of any treatment.)

Acamprosate

Acamprosate (Campral) calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). Studies indicate that it reduces the frequency of drinking and, in concert with psychotherapy, improves quality of life even in patients with severe alcohol dependence. One study reported that 60% of patients remained abstinent for 12 weeks, and in another 43% were still abstinent after nearly a year. The drug may cause occasional diarrhea and headache. It also can impair certain memory functions but does not alter short-term working memory or mood. People with kidney problems should use acamprosate cautiously. Combination therapy with naltrexone or disulfiram may be possible and helpful. The drug is available overseas and in Latin America and is under review in the U.S.

Antidepressants

Depression is common among alcohol-dependent people, and it can be a significant problem in people who quit drinking. In fact, one 2002 study found that quitting drinking was associated with a fourfold increase in the risk for major depression. Antidepressants may be helpful, particularly for patients who have a history of depression. Experts reporting on the study suggested that treating these individuals with antidepressants as soon as they quit drinking may help prevent relapse. Some studies suggest they may help reduce drinking but do not appear to have any effect on alcohol dependence itself.

SSRIs. Selective serotonin reuptake inhibitors (SSRIs) target the neurotransmitter serotonin and are of particular interest in the treatment of alcoholism. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluvoxamine (Luvox). Studies indicate that these antidepressants may reduce cravings and desire for alcohol, even in selected people who are not depressed. Studies report reductions in alcohol ranging from 10% to 70% in people with alcoholism who take SSRIs. Research is under way to determine which individuals with alcoholism might best respond to SSRIs. For example, one study suggested that they may be more effective for men than women. Some may be specifically helpful for people with both alcoholism and certain anxiety disorders, such as social anxiety.

Designer Antidepressants. A number of drugs have now been developed that target other neurotransmitters, such as norepinephrine, alone or in addition to serotonin. They include nefazodone (Serzone), venlafaxine (Effexor), and mirtazapine (Remeron). Some research suggests they may have some benefits for treating alcoholism.

Ondansetron

Ondansetron (Zofran) is ordinarily used to prevent nausea and vomiting due to chemotherapy. It also has actions that affect serotonin, a neurotransmitter that helps regulate alcohol's effects. In one study, ondansetron helped reduce drinking in people with early-onset alcoholism, although not in people who began drinking after age 25. These results suggest that this agent is helpful in patients with genetically related alcoholism, although not with alcoholism caused by other factors.

Investigative Agents

Topiramate. Topiramate (Topamax) is anti-seizure agent used to treat epilepsy. It also helps control impulsivity and early studies indicate it might reduce craving in patients with alcoholism. Most side effects are mild to moderate and include mood swings and behavioral problems, dizziness, fatigue, visual disturbances, tremor, impaired concentration and thinking, weight loss and diarrhea, and a higher risk for kidney stones.