Medication Assisted Treatment for Alcohol Addiction

Now called Alcohol Use Disorder, alcohol dependence and addiction is far more prevalent than opioid addiction.

Alcohol in high concentration is toxic to tissues … it affects every part of the body. It damages your stomach, your liver, your brain, and your heart.

Like any other addiction, it gradually destroys personal relationships, professional performance, financial stability, and causes legal troubles.

Once alcohol usage has reached the point of dependence, or addiction … personal will and resolve to stop using it may not be sufficient.

Any attempt to discontinue using it leads to withdrawal symptoms, and inability to function normally. If you are unable to do it by yourself … let medical science help you.

Common withdrawal symptoms

Craving, anxiety, inability to concentrate, tremors, lack of appetite, headache, irritability, sweating, rapid heart rate, confusion, inability to sleep, and nightmares.

Usually this is relieved by consuming alcohol … and that is what most people end up doing … and the cycle continues.

The more extreme form of withdrawal is called “Delerium Tremens”. It happens in people who have been using alcohol for a very long time, and in large quantities, who have suddenly no access to alcohol, … it takes a few days to develop. The symptoms are very dramatic; they include confusion, shaking, agitation, hallucinations, seizures, vomiting, and dehydration. If allowed to progress to this point … it will require a visit to the Emergency Room or an inpatient facility.

Alcohol withdrawal is rarely seen … because beer is available at every intersection, and drinking is socially acceptable.

Do you have alcohol dependence or addiction?

The test is simple … and can be done at home. Go without any alcohol for a week or two, and see if you feel normal … if not, then you have alcohol dependence.

Do you need to be treated by a doctor, … with medications?

Not necessarily. If you have not damaged your liver, have mild symptoms of withdrawal, then progressively reducing your alcohol use, in quantity, as well as frequency, … may be enough. But if you can not do that … then it is in your interest to seek professional help.

You may also need professional help if your alcohol use is causing personal, professional, financial, or legal problems.

There are anecdotal reports of other medications being helpful in the treatment of alcohol addiction, such as,… Fluoxetine (Prozac), Sertraline (Zoloft), Topiramate (Topamax), Ondansitron (Zofran), Baclofen, Gabapentin (Neurontin), Buprenorphine (Suboxone), Bupropion (Welbutrin), etc. At present none of these drugs have been approved by the FDA for the treatment of alcohol addiction.

How do these medications work?

Most of these medications work on receptors in your brain. They were never designed to treat alcohol addiction, but over the years they were found to have beneficial effects and were further studied and approved if they did make a significant difference in the treatment of addiction.

The same medication does not work for everyone, and one may have to try more than one medication to find the one that helps them most. I prefer to start treatment with Naltrexone and add or substitute Acamprosate if the results are not satisfactory. Naltrexone dosing is more convenient, and the medication cost is much less than Acamprosate. The duration of medication assistance typically is 3 to 6 months, rarely upto one year. People who wish to follow “The Sinclair Method” should be prepared to take Naltrexone for six months to a few years.

Naltrexone is an opioid blocker, average dose is 50 mg tablet by mouth, once a day. It can not be prescribed to patients who are taking opioid medications for pain. It has to be used with caution in patients who have liver damage. It can be used in patients who have addiction to alcohol as well as opioids. It is also available as a once a month injection under the brand name Vivitrol.

Acamprosate is believed to act through NMDA, glutamate, and calcium channel receptors. The precise mechanism is not exactly known, however, the clinical effect is well established … it reduces craving for alcohol and thereby reduces the amount of alcohol consumed. It is more effective if started after the patient has been abstinent for a few days. It is available as 333mg tablets. One can start at one tablet, three times a day and gradually increase to the recommended dose of two tablets, three times a day (six tablets per day).

Naltrexone and Acamprosate are known to reduce craving. Not everyone is cured, … mostly because patients drop out of the program, but even a partial success is good. Even if one does not achieve the goal of complete abstinence; … simply reducing the total amount of alcohol consumed to say one to two drinks, reduces the behavioral problems that are associated with the heavy use of alcohol … behaviors like aggression, lack of control and poor judgment. Less alcohol used means lower vulnerability to crime and assault, … lower risk of accidents and injuries. Simply reducing the total amount of alcohol consumed daily, reduces its cumulative toxic effect on the body organs, with an improvement of health in the long run.

Disulfiram (Antabuse) works by preventing the body’s ability to process alcohol, by blocking acetaldehyde dehydrogenase, … in the process creating an accumulation of acetaldehyde in the blood, which produces extremely unpleasant symptoms. Within 5 to 15 minutes of consuming alcohol patient will experience skin flushing, sweating, throbbing headache, anxiety, breathing difficulty, rapid heart rate, nausea and vomiting, … it is not fun to watch much less to experience. In severe cases it may progress to chest pain, low blood pressure, irregular heart beat, loss of consciousness, convulsions, circulatory collapse, and even death.

The fear of the unpleasant symptoms is what deters patients from using alcohol. The fear of stupidity on the part of the patient is what deters doctors from prescribing it.

The dose is 250mg to 500mg once a day. People can beat the deterrence by not taking the medication … and some are reckless enough to consume alcohol while being on this medication … that invariably requires an emergency room visit. It is for these reasons that I do not recommend it. It was the only medication for alcohol deterrence for a long time, but now we have better medications … and gentler methods.

Addiction is not cured by a pill. Some people do have have miraculous success, … the rest will have at least some success. It makes giving up alcohol a little easier and in almost every case case it reduces the frequency and the amount of alcohol consumed. You can improve your chances of success by working with an addiction counselor or therapist, … to modify your behavior.

Advantages of Naltrexone and Campral

1. These medications are prescribed by a medical provider, dispensed by a pharmacy, and are taken in the comfort and privacy of your home. You can be in treatment without your colleagues knowing about it.
2. You do not need to go to a hospital or rehab facility to start this treatment. It is a convenient out patient program that requires once a month follow-up visits.
3. Outpatient treatment costs are low enough that the majority of patients do not need to use their health insurance.
4. Patients can also get this treatment from their primary care provider; … if the PCP is familiar with the medication and is willing to provide treatment and follow up.
5. You do not have to be completely abstinent from alcohol to start these medications, that means you do not have to go into  withdrawal to start the treatment.
6. These do not interact with alcohol. You will still feel the effects of alcohol, but the medications will not make it any worse.
7. The treatment is not stopped even if the patient has a relapse.
8. These medications do not cause any sedation, so they are safe with driving or working with machinery.
9. They reduce the craving and urge to drink over time, and reduce the total amount of alcohol intake.
10. These medications are not addictive. Discontinuing the treatment has no withdrawal effects.
11. If it can prevent even one DUI … you will recover the cost of treatment.

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Naltrexone, because of its ease of single daily dose is the preferred drug in my practice. For patients who can not be prescribed Naltrexone, Acamprosate(Campral) is the next choice.

Unlike Buprenorphine (Suboxone), Naltrexone and Campral are not controlled substances, do not require special certification by DEA for prescription, and there is no patient limit.

Ask your Primary Care Provider for treatment … or referral to a treating physician.

 

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Fee schedule:
Initial enrollment: $228
Follow up visits (once a month): $98
(Typical duration of treatment is 3 to 6 months)
Urine drug screens are included.
Blood tests are not included.

Blood tests can be done through your PCP. No special test is required.
CHEM-7 is a test that is routinely done by your PCP and it includes basic liver enzymes level and BUN/Creatinine levels.

Approximate cost of medications:

Naltrexone: $1-$2 per 50 mg tablet. Cost per month $50 to 100. (30 tablets per month)

Acamprosate: $1 to $1.50 per 333mg tablet. Cost per month $180 to $270. (180 tablets per month)

Naltrexone is covered under most prescription plans. You can confirm coverage and conditions attached by calling your prescription plan, or searching for the medication through prescription plan website.

Medication costs at local pharmacies can be determined through https://www.goodrx.com/