This is the protocol that I follow in my clinic for the treatment of Alcohol Use Disorder.
This protocol is different from the Naltrexone protocol for opioid use disorder.
Phone interview: Patients are offered an appointment after a brief phone interview. The purpose of the interview is to ascertain patient’s suitability for my program and disclose the limitations of my program so that patients can make an informed decision for their treatment.
This is an outpatient program. Patients continue to work, and live with their family … it reduces the cost of treatment, and avoids disruption of their normal life. Treatment is carried out from a doctor’s office in the community, like any other chronic disease … and eliminates the need to camouflage embarrassing absences that is necessary when attending inpatient rehab.
I am not a provider for any insurance network. If you have insurance coverage then you should look for a provider within your network. Your PCP may provide the prescription or refer you to an addiction specialist. All or most of the services, for example Naltrexone prescription, counseling and behavior therapy, lab tests, testosterone replacement therapy, etc., may be covered by your insurance and can be obtained through the participating providers.
How does the program work?
There are three components to the program:
- The medication Naltrexone obtained by prescription.
- Self imposed barriers to the use of alcohol.
- Substitution. You do not have to derive all your pleasures from alcohol. Substitute safer and healthier means of pleasure.
Behavioral changes, either by Self-discipline, or with the help of addiction counselor, or behavioral therapist, is required to derive lasting benefit. Once those changes have been made, and are permanent, then the medication is gradually reduced and discontinued, … or it is taken only before anticipated alcohol use.
Naltrexone – Mechanism of action: Naltrexone acts by blocking the opioid receptors in the brain and thus preventing other chemicals from triggering the cascade of pleasure-reward-reinforcement system. Alcohol is one of the chemicals that triggers this cascade. By taking this medication before alcohol is consumed, this pleasure is reduced … and so is the reward … and that leads to less reinforcement.
By adding some barriers to alcohol use and instituting behavior modification … one is able to reduce alcohol use to safe levels, … or eliminate it entirely.
Benefit over Disulfiram (Antabuse): Naltrexone is safer, it does not interact with alcohol, and does not precipitate any unpleasant, or life threatening symptoms if the patient does consume alcohol.
On the other hand alcohol metabolism is blocked by Antabuse, and the intermediary chemical that is produced causes very unpleasant symptoms … flushing, headache, nausea, vomiting, palpitations, chest pain, hyperventilation, hypotension, and collapse.
So patients on Antabuse try to beat the system by not taking the medication, … and those with poor control consume alcohol anyway, … triggering a reaction that scares everyone around them, and requires an ER visit, … in rare cases may even cause death. That is why most doctors are reluctant to prescribe Antabuse.
In the past Antabuse was the only option, but now, with Naltrexone, we have a safer and gentler method.
Naltrexone does not block the effects of alcohol … if you do drink, you will still be drunk.
Alcohol use will still cause poor judgment, and facilitate aggression and inappropriate behavior. Alcohol use will still cause slowing of reflexes, blurred vision, slurred speech, loss of balance, in-coordination, … DUI, accidents, and legal problems.
Naltrexone will not protect against the toxic effects of alcohol on stomach, liver, brain, and heart.
Naltrexone can not be prescribed to a patient who is taking opioid medications for pain. One, it will push the patient into withdrawal, and two, it will block the effect of pain medications … and will exacerbate the pain.
Initial visit: Allow two hours. Involves completion of application form, disclaimers, consent, medical history forms, medical examination, urine drug screen, discussion of treatment, and prescription. A follow up appointment is scheduled after three weeks. Naltrexone is prescribed as 50mg tablets once a day, one to two hours before consuming alcohol.
Follow up visits: Once a month, 15 to 30 minutes. In between appointments there is brief follow up as necessary, over the phone.
The first follow up appointment is after three weeks. You will still have one week worth of medications; this way you will always be ahead by one week on your prescriptions. If you miss the appointment you will not be in any crisis, and will have a few days to make up … without any break in therapy. After the second visit, follow up appointments are made once every four weeks.
After three visits if everything has gone well and you are making satisfactory progress, you will be given one refill on each prescription and will be seen once every two months, … for as long as you need it.
The counseling that I provide is limited and problem focused, … useful tips to reduce your drinking. This is not a substitute to the counseling that you should receive from a qualified substance abuse counselor, or a behavioral therapist. You can negotiate with them as to how frequently you would like to receive counseling, … I recommend at least once a month.
Naltrexone is initially prescribed at 50mg once a day. Depending on achievement of treatment goals, … or failure to achieve treatment goals, and review of liver enzymes, review of side effects, review of drug drug interactions if any, … the treatment is adjusted. The treatment dose can be easily titrated upwards up to 150mg/day of Naltrexone. A maximum dose of 300mg can be used, but I have never had to prescribe that dose.
Naltrexone Costs: The cost of Naltrexone tablets is about $1 to $2 per tablet, ($30 to $60 per month) and it is covered by most prescription plans. Naltrexone is not a controlled substance and can be prescribed by your PCP, including Nurse Practitioners and Physician Assistants. Unfortunately many Primary care Providers have a busy practice and do not want to be involved with initiating or following up with this course of treatment … and may refer you to a psychiatrist or addiction specialist.
If the progress is inadequate then I recommend adding Campral (Acamprosate) two tablets three times a day. Or if the patient does not wish to use Naltrexone, or can not use it because of side effects, … then Campral is prescribed. Campral is taken two tablets three times a day and the total stated cost per month of the prescription is about $250 to $300, may be lower with coupons.
So far I have not had to prescribe Campral. Some patients that did not make adequate progress could have used it … but they dropped out of my program, or declined to use Campral.
What is the success rate?
Depends. If success is measured by reduced number of drinks, then the success rate is 100 percent. If success is measured by reducing drinking to safe levels or completely eliminating it … then the success rate has not been that good, may be 20 percent. Most patients drop out, because they were expecting a miracle. Unfortunately addiction is not cured by a pill … it is primarily a behavior problem, and for most people, changing behavior requires a lot of effort … over a long period of time.
Addiction like any chronic disease at the best can be managed … managed to the best of our ability. Not reaching the point of complete cure is not failure. Patients come to the program only after they have failed in controlling their drinking on their own … so any further reduction in drinking is success.
Any reduction in drinking improves their health and well being, reduces future healthcare costs, prolongs their life, reduces the risk to society, improves their productivity, and helps the patients take care of themselves and their family.
Do you prescribe Vivitrol Injection
No, I do not. Most of my patients are self-pay patients and find the cost of Vivitrol Injection to be unreasonable. Naltrexone tablets, per month cost is $30 to $60. Vivitrol injection, which lasts one month, costs $1100 to $1300. With tablets one can increase or decrease the dose, or even stop it if the patient is unable to tolerate it. Injection once given is given, and the dose can not be altered. Patients still need to have a trial of Naltrexone tablet before they can be prescribed the injection.
The only advantage of the injection is once a month dosing. Pop a pill once a day … and save a thousand dollars.