Using medicine to try to deal with alcoholism

Issue June 2005

Q:I have a question about the utility of medicines for alcoholism, particularly with regard to my husband, who has never latched onto AA or counseling. One of my friends has recommended Antabuse, while another friend with experience in this area says it’s useless. Are there other alcoholism medications as well?
A:Antabuse (generic name disulfiram) has been around since 1948. It blocks the normal metabolism of alcohol, causing a buildup of a chemical called acetaldehyde. This buildup triggers an immediate and extremely uncomfortable physical reaction described as “a combination panic attack and stomach flu.” It can be severe enough (depending in part on how much alcohol is ingested) to call for emergency room treatment. One hears that this reaction could in theory be lethal, but we have never come across such a case.
The idea, of course, is that fear of the severe Antabuse reaction to drinking will act as a deterrent to the impulse to drink and buy time for the recovering individual to develop sobriety skills, i.e., new ways of thinking and coping.
Some have been disappointed in the effectiveness of Antabuse, because many alcoholics find a way to rationalize discontinuing the medication. When a sufficient number of days has elapsed, they have regained the option to drink without a reaction. Thus, the motivation to avoid that first drink, despite any temptations, cravings, or urges, must be quite strong.
In order to avoid subverting the benefit of Antabuse in this way, some people will establish an “Antabuse Contract” with an observer, such as a spouse. Antabuse, which is only applicable to alcoholism, is generally not prescribed to individuals with compromised livers or heart disease.
Two other medications have been developed to help with recovery from alcoholism. Campral (generic: Acamprosate), widely used in Europe to reduce alcohol craving, is now FDA-approved for use in the U.S. to decrease relapse to heavy drinking in abstinent alcoholics. It appears to help re-stabilize neurotransmitter systems that suffer changes because of long-term drinking. Though reversible within weeks or months of sobriety, these changes appear to be responsible for relapse-inducing discomforts, e.g., anxiety, irritability, and sleep interference.
Another drug, ReVia (Naltrexone), originally used to treat narcotic addiction, also reduces relapse to alcohol. It is believed to act on certain opiate receptors in the brain by blocking the release of dopamine in the brain’s “reward system” that produces alcohol-related euphoria. Drinking no longer produces a buzz and ReVia therefore reduces craving.
A reportedly more potent and long-lasting version of ReVia is Revex (Nalmefene), which blocks all opiate receptors. A third drug, Topomax (Topiramate), is an anti-seizure medication that is also commonly used to stabilize moods. Although this drug is not yet FDA approved, a recent study suggested it may reduce drinking and craving in alcohol-dependent patients.
The effectiveness of these drugs, which are not without mild to moderate (but usually short-term) side effects, depends on the desire to stop drinking. All are adjuncts rather than substitutes for psychosocial interventions such as counseling and self-help groups. Our experience suggests that those who would use medications as stand-alone treatment for alcoholism would be at especially high risk for relapse.
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