NIH says doctors are neglecting drug treatments for alcohol addiction


Naltrexone, which is also used to help treat opioid addiction, was approved for use in alcohol addiction in 1994.

As millions of Americans struggle with alcohol abuse problems each year, public health officials suggest two oft-overlooked drugs may provide relief for some.

More than 18 million people abuse or are dependent on alcohol, but a key federally-funded study reported last year that only 20 percent will receive treatment of any kind. In fact, just over a million people seek any type of formal help, from meeting with a counselor or doctor to enrolling in a specialized treatment program.

Recognizing that for many people, peer support programs, such as Alcoholics Anonymous, work well, federal officials also want to encourage physicians to become more involved in identifying and treating alcohol problems and seek to increase awareness of drug treatments.

“We want people to understand that we think AA is great, but there are other options,” said George Koob, director of the National Institute of Alcohol Abuse and Alcoholism, part of the federal National Institutes of Health. “May a thousand flowers bloom, everything helps. “

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The NIAAA has developed a dedicated drug development arm and supports drug trials to provide more options for patients and physicians.

The NIAAA and the Substance Abuse and Mental Health Services Administration also asked an external panel of experts to report last summer on drug options.

“Current evidence shows that the drugs are underused in the treatment of alcohol use disorders, including alcohol abuse and dependence,” the panel reported. He noted that although public health officials and the American Medical Association declare alcohol dependence a medical problem, there continues to be “considerable resistance” among physicians to this approach.

It is still rare for a person with an alcohol use disorder to even hear that there is medication available. This in part reflects the overwhelming tradition of treating alcohol abuse through 12-step programs. It is also a by-product of the limited promotion by drug manufacturers and the confusion among doctors about how to use them.

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Naltrexone and acamprosate are the two drugs on the market for patients with alcohol cravings.

“These are very safe drugs,” Koob said. “And they have been effective.”

A 2014 analysis in the Journal of the American Medical Association of earlier studies found that both drugs “were associated with a reduction in the return to alcohol use.”

For a North Carolina woman wanting to get sober, naltrexone provided that help. Dede said she had attended hundreds of Alcoholics Anonymous meetings. She spent time in two different rehabilitation facilities, one of which cost her $ 30,000 out of pocket. But she always struggled.

“Self loathing was the worst thing about it,” she said. “I hated myself as an alcoholic, but I couldn’t stop myself.”

Eight years ago, she decided to try another approach: meetings for people with alcohol problems with counselors from the University of North Carolina at Chapel Hill. It was there that she first heard of naltrexone.

One of the counselors mentioned Dr. James C Garbutt, a professor of psychiatry who treats patients with alcohol use disorders, often using naltrexone. She asked to get a date with him, but was told it would take weeks to fit in. She wouldn’t wait that long. Instead, she showed up to the doctor’s waiting room and stayed until he could see her.

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“I begged. I really begged to be able to see him,” she explained.

With the help of naltrexone and one-on-one advice, Dede said she hadn’t had more than two sips of wine since that visit. She agreed to be interviewed on the condition that Kaiser Health News only use her nickname because she tried to keep her alcohol abuse private.

A third drug is also available, but it does not work against alcohol cravings. Disulfiram, also known by the brand name Antabuse, makes people seriously ill when they drink alcohol. It has been shown to be less effective in helping curb alcohol abuse than the other two drugs.

Naltrexone, which is also used to help treat opioid addiction, comes in 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 alcohol problems only. It comes in tablet form.

When naltrexone hit the market, sales teams struggled to explain how the drug worked differently from Antabuse to non-physician administrators who made treatment decisions at drug addiction clinics, addiction experts said. Many have misunderstood how and for whom the drug works. Part of that persists today.

“They got three years” of commercial exclusivity, said Dr. Henry Kranzler, director of the Center for Studies of Addiction at the University of Pennsylvania. “Three years is not a long time to create a market where there really isn’t a lot of market and they haven’t.” The company halted its efforts to market the drug in 1997.

Many of the same marketing problems also persist for acamprosate.

Part of the history of naltrexone in the treatment of opioids has also damaged its image. The drug blocks the effects of opioid receptors in the brain. Thus, all the patients who took them without having completely detoxified from the opiates were launched into an agonizing withdrawal. The label urged doctors to only prescribe the drug to patients who had already been opioid-free for at least 10 days.

But it does not have the same effect on patients with alcohol use disorders. A patient who drinks while taking naltrexone will get drunk and not have these withdrawal symptoms. Yet when the drug was approved for alcohol use disorders in 1994, the label still stated that patients had to be completely sober before using naltrexone.

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Often healthcare providers view complete abstinence as the only positive outcome of treatment, but patients who drink while taking naltrexone get drunk without the reward of opioids to reinforce behavior. The absence of this reward makes drinking alcohol less attractive in the future.

Garbutt, who was on the expert panel last year, encourages total abstinence for his patients, but also supports patients who prefer to set a harm reduction goal.

“If we can reduce your intake by 80% and dramatically reduce your heavy drinking days, that is also a very positive thing,” he said. “Some people just aren’t ready. The idea of ​​sobriety is just too big a concept for them to remember.” And naltrexone can help patients with either of these goals: abstinence or reducing alcohol consumption.

In fact, Garbutt explained, although naltrexone helps patients stay sober, “the effect of reducing binge drinking is the most important effect of naltrexone.”

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