Addiction Treatment Medications Are Underused

A 2014 JAMA study has found that doctors underutilize drugs that treat alcoholism. The report, analyzing over 120 studies on medications to treat alcohol cravings, showed that acamprosate and oral naltrexone proved to be the most effective.

Led by Daniel Jonas of the University of North Carolina at Chapel Hill, the team looked at 122 randomized clinical trials and one cohort study totaling almost 23,000 subjects. According to the analysis, acamprosate and naltrexone were found to be effective. The researchers concluded that treatment for alcohol use disorders could be aided by these medications; however, the fact remains that less than 10% of patients in recovery receive medication. Why?

Dark history of drugs to treat alcoholism

“There is a long and dark history to the use of drugs in the treatment of alcoholism,” says Percy Menzies, the president of Assisted Recovery Centers of America Midwest in Missouri. “Drugs like morphine, cocaine, beer, LSD, benzodiazepine…were seen as cures, and these drugs did more harm than good.”

The first drug approved by the FDA to treat alcoholism was disulfiram, or Antabuse, in 1951. It works by causing extreme symptoms of a hangover, including vomiting. “It was seen as a punishment,” Menzies says. “We have a much better understanding of the neurochemistry of alcoholism these days, and thus, a much better arsenal for pharmacological attack.”

A new generation of addiction pharmacology

Newer medications like naltrexone and acamprosate came online in the 1990s. The FDA originally approved naltrexone in 1984 to treat opioid addiction, but it’s used more regularly these days—when it is used—to treat alcoholism, for which it was approved 10 years later.

The FDA approved injectable naltrexone, marketed under the brand name Vivitrol, in 2006. Vivitrol is taken intramuscularly in injectable doses once a month (compared to a smaller daily dose via the oral route). As an opioid receptor antagonist, naltrexone works by blocking the euphoric effects of alcohol. In other words, it blocks the high that alcohol triggers by way of endorphins, the brain’s endogenous opioids.

Another medication, acamprosate (brand name Campral) was approved in 2004. While the mechanism of action isn’t fully known, it is thought to stabilize the chemical imbalance in the brain brought on by alcohol abuse, possibly by antagonizing the NMDA (glutaminergic) receptors and/or agonizing the GABA type A receptors. Both drugs are prescribed after a patient gets sober, to help deal with cravings and the post-acute withdrawal period.

“All the medications work on the neurochemistry of the brain and specifically the neurochemicals involved in the reward centers,” Menzies says. “Alcohol impacts GABA, serotonin and endorphins.”

According to NIH numbers, about 18 million people in the U.S. have an alcohol use disorder. Medications to decrease these numbers are “considerably underused,” the authors conclude in the JAMA study, adding that most doctors aren’t even aware that they exist. However, along with counseling and a recovery program in place, pharmacologic interventions could go a long way toward reducing relapse rates.

Medication is one component of an effective treatment program

Studies showing efficacy of medications to treat alcoholism do have defects. Stuart Gitlow, President of the American Board of Addiction Medicine, says “As a result of improper inclusion criteria, useless outcome measures, and poor efforts at control, many addiction specialists are ignoring the more recently released medications for alcohol addiction.”

In an article for Addiction Pro, he clarified: “These treatments alone cannot treat alcohol dependence…  All of the bad learning, habits and conditioning associated with alcohol just go into hibernation and wait for the appropriate but usually most inopportune time to manifest themselves in a relapse.”

In the long term, it might be worse using these medications without also addressing the root cause of drinking. Gitlow isn’t saying alcoholics shouldn’t use medications, just that short-term studies are not exactly improving how alcoholism is treated.

“Cessation of sedative use is the first step toward recovery, but then the real work begins,” he writes.

None of these medications is a cure-all. In fact, medications have been shown to work best in conjunction with counseling. “The most effective treatment is hitting the disease from both angles, which includes therapy and medication,” Menzies says.

The critical role of medication in preventing overdose

Improving outcomes by reducing overdose deaths is critical. When addicts get sober, their tolerance goes down. Upon leaving treatment, using again could be deadly. “Anti-craving medications like Vivitrol have great potential to improve outcomes [in that they can] reduce overdoses and deaths among patients returning home after residential treatment or incarceration,” Menzies says. “The ‘deprivation’ effect is well-known, but often ignored. When patients are discharged on drugs like Vivitrol, they have a month’s protection from relapsing and deciding what they want to do. If 50% of the residential programs discharged on Vivitrol, we could change the face of addiction.”

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