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 percent 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.
Safe, effective
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.
Naltrexone and acamprosate are the two drugs on the market for patients with alcohol cravings.
“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.”
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.
Misunderstandings
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.
