Alcoholism medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## Overview

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## Medical Therapy

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Treatments for alcoholism are quite varied because there are multiple perspectives for the condition itself. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.

Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.

Randomized controlled trials of volunteers show benefit from topiramate.[1][2]

"Acamprosate appears to be an effective and safe treatment strategy for supporting continuous abstinence after detoxification in alcohol dependent patients" according to the Cochrane Collaboration.[3] In this review, the number needed to treat was about 9 patients.

#### Contraindicated medications

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Alcoholism is considered an absolute contraindication to the use of the following medications:

* Methotrexate

## ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) [4]

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### Recommendations for Ventricular Arrhythmias in Alcoholism

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Class I

"1. Complete abstinence from alcohol is recommended in cases where there is a suspected correlation between alcohol intake and ventricular arrhythmias. (Level of Evidence: C)"
"2. Persistent life-threatening ventricular arrhythmias despite abstinence from alcohol should be treated in the same manner that such arrhythmias are treated in patients with other diseases, including an ICD, as required, in patients receiving chronic optimal medical therapy and who have reasonable expectation of survival for more than 1 y. (Level of Evidence: C)"

### Effectiveness

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The effectiveness of alcoholism treatments varies widely. When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own.[5] A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed.[6]

### Detoxification

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Main article: Alcohol detoxification

Alcohol detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to prevent  alcohol withdrawal.

Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting.

### Group therapy and psychotherapy

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After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.

The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service. Alcoholics Anonymous was the first group, and has more adherents than all other programs combined. Some of the others include LifeRing Secular Recovery, Rational Recovery, SMART Recovery, and Women For Sobriety.

### Rationing and moderation

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Rationing and moderation programs such as Moderation Management and The HAMS Harm Reduction Network do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. However, this group showed fewer initial symptoms of dependency.[7] A follow-up study, using the same NESARC subjects that were judged to be in remission in 2001-2002, examined the rates of return to problem drinking in 2004-2005. The major conclusion made by the authors of this NIAAA study was "Abstinence represents the most stable form of remission for most recovering alcoholics". [8]

### Pharmacotherapy

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A variety of medications may be prescribed as part of treatment for alcoholism.

* Antabuse (disulfiram) prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hangover symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast-acting and long-lasting uncomfortable hangover. This discourages an alcoholic from drinking in significant amounts while they take the medicine. A recent 9-year study found that incorporation of supervised disulfiram and a related compound carbamide into a comprehensive treatment program resulted in an abstinence rate of over 50%. [9]

* Naltrexone is a competitive antagonist for opioid receptors, effectively blocking our ability to use endorphins and opiates. Naltrexone is used in two very different forms of treatment. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction, combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcohol addiction.
Naltrexone comes in two forms. Oral naltrexone, originally but no longer available as the brand ReVia, is a pill form and must be taken daily to be effective. Vivitrol is a time-release formulation that is injected in the buttocks once a month.

* Acamprosate (also known as Campral) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse...Campral proved superior to placebo in maintaining abstinence for a short period of time..."[10] While effective alone, it is often paired with other medication treatments like naltrexone with great success.[11][12] Acamprosate reduces glutamate release. The COMBINE study was unable to demonstrate efficacy for Acamprosate.[13]

* Topiramate (brand name Topamax), a derivative of the naturally occurring sugar monosaccharide D-fructose, has been found effective in helping alcoholics quit or cut back on the amount they drink. In one study heavy drinkers were six times more likely to remain abstinent for a month if they took the medication, even in small doses.[14] In another study, those who received topiramate had fewer heavy drinking days, fewer drinks per day and more days of continuous abstinence than those who received the placebo.[15] Topiramate works by reducing dopamine so that drinkers no longer get any pleasure from consuming alcohol and is the only medication shown to be effective for persons who are still drinking.

## References

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1. ↑ Johnson BA, Rosenthal N, Capece JA, Wiegand F, Mao L, Beyers K; et al. (2008). "Improvement of physical health and quality of life of alcohol-dependent individuals with topiramate treatment: US multisite randomized controlled trial". Arch Intern Med. 168 (11): 1188–99. doi:10.1001/archinte.168.11.1188. PMID 18541827.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ Johnson BA, Rosenthal N, Capece JA, Wiegand F, Mao L, Beyers K; et al. (2007). "Topiramate for treating alcohol dependence: a randomized controlled trial". JAMA. 298 (14): 1641–51. doi:10.1001/jama.298.14.1641. PMID 17925516.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ Rösner S, Hackl-Herrwerth A, Leucht S, Lehert P, Vecchi S, Soyka M (2010). "Acamprosate for alcohol dependence". Cochrane Database Syst Rev. 9: CD004332. doi:10.1002/14651858.CD004332.pub2. PMID 20824837.CS1 maint: Multiple names: authors list (link)
4. ↑ Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Spontaneous Recovery in Alcoholics: A Review and Analysis of the Available Research, by R. G. Smart Drug and Alcohol Dependence, Vol. 1, 1975-1976, p. 284.
6. ↑ Based on information from Dr. Mark Willenbring of the National Institute on Alcohol Abuse and Alcoholism, the February 2007 issue of Newsweek \- Adler, Jerry; Underwood, Anne; Kelley, Raina; Springen, Karen; Breslau, Karen. "Rehab Reality Check" Newsweek, 2/19/2007, Vol. 149 Issue 8, p44-46, 3p, 4c
7. ↑ Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. 2005. Recovery from DSM-IV alcohol dependence: United States, 2001-2002.  : Addiction. Mar;100(3):281-92
8. ↑ Dawson DA, Goldstein RB, Grant BF. 2007. Rates and correlates of relapse among individuals in remission from DSM-IV alcohol dependence: a 3-year follow-up. Alcohol Clin Exp Res. 2007 Dec;31(12):2036-45.
9. ↑ Krampe, H., Stawicki, S., Wagner, T., Bartels, C., Aust, C., Ru¨ ther, E., Poser, W., and Ehrenreich, H. 2006. Follow-up of 180 Alcoholic Patients for up to 7 Years After Outpatient Treatment: Impact of Alcohol Deterrents on Outcome. Alcohol Clin Exp Res,30(1):86-95.
10. ↑ "FDA Approves New Drug for Treatment of Alcoholism". Retrieved 2006-04-02."
11. ↑ "Effect of oral acamprosate on abstinence in patients with alcohol dependence in a double-blind, placebo-controlled trial: The role of patient motivation". 2006-03-17. Retrieved 2006-04-10.
12. ↑ "COMBINED ACAMPROSATE AND NALTREXONE, WITH COGNITIVE BEHAVIOURAL THERAPY IS SUPERIOR TO EITHER MEDICATION ALONE FOR ALCOHOL ABSTINENCE: A SINGLE CENTRES' EXPERIENCE WITH PHARMACOTHERAPY". 2006-02-08. Retrieved 2006-04-10.
13. ↑ "Naltrexone or Specialized Alcohol Counseling an Effective Treatment for Alcohol Dependence When Delivered with Medical Management". 2006-05-02.
14. ↑ Johnson, Bankole A., et al. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. The Lancet, 2003, 361(9370), 1677-1685: Swift, B. Topiramate for the treatment of alcohol dependence: initiating abstinence. The Lancet, 2003, 361(9370), 1666-1667
15. ↑ Johnson, Bankole A., et al. Topiramate for Treating Alcohol Dependence - A Randomized Controlled Trial. Journal of the American Medical Association, 2007 (October), 298(14), 1641-1651

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