In this new feature, we will discuss topics about medication and medical issues that come up when treating substance abuse. This month we are speaking with Alex Horowitz, MD. Dr. Horowitz is a psychiatrist who is board certified in both general psychiatry and addiction psychiatry. He is a clinical assistant professor at NYU School of Medicine and in full-time, private practice in Midtown Manhattan. To contact Dr. Horowitz, you can email him at [email protected].
Today we are discussing medication to help people stop or reduce their drinking. What are the main medications and how do they work?
The main medications that I commonly prescribe today that have shown benefit in treating alcohol use disorders include disulfiram (brand name Antabuse), naltrexone (available as a daily pill or a monthly injection under the brand name Vivitrol), acamprosate (brand name Campral), topirimate (brand name Topamax). Baclofen and gabapentin (brand name Neurontin) are also sometimes used. Moving forward, I will refer to the medications primarily by their brand names, as I believe that this is how they are best known to the general public.
Antabuse is the only one of these medications that someone who is taking CANNOT drink on, whereas that is not the case for the other medications. When a person drinks alcohol, the body initially converts the alcohol into a toxic substance called acetaldehyde. Then an enzyme called aldehyde dehydrogenase quickly breaks down the toxic substance. Antabuse works by blocking aldehyde dehydrogenase, resulting in an accumulation of acetaldehyde which the body doesn’t really want. The outcome is that drinking alcohol while on Antabuse leads to getting sick/feeling very uncomfortable. Symptoms include feeling flushed, racing heart, and vigorous vomiting. In this manner Antabuse can work very well as an aid for someone who is committed to stopping drinking but is struggling to do so. By taking Antabuse every day, the knowledge that they will get sick if they drink should greatly reduce the chances of having a drink.
In contrast, all of the other medications listed work in different ways to reduce alcohol cravings. While they can decrease one’s desire to drink, they do not make a person sick if the person does drink while on these medications. Studies have shown that people who have chosen to stop drinking are more likely to succeed for more time if on one of these medications. If they do drink, they are less likely to drink as much. Patients have described to me a decreased desire to drink as well as decreased interest in continuing to drink if they do have a drink.
How would someone know if they are a good candidate for these medications?
Someone who is trying to stop drinking or trying to cut down on drinking and is struggling to do so is likely a good candidate for one or more of these medications. He or she should consult with an addiction psychiatrist or other physician with expertise in treating addiction, who can perform a thorough evaluation, including a medical history and bloodwork, to determine the risks and benefits of taking such medications.
Let’s focus for a minute on Antabuse. It has an effect on your liver . . . is it potentially damaging to your liver? What about if you take it for a long time, is that dangerous for your health?
Antabuse is broken down by the liver. While most people who take Antabuse do not have any effects on their liver, it is toxic to the liver in a portion of people who take it. For this reason, blood tests should be done prior to starting Antabuse and then regularly to check for evidence of liver damage in people taking Antabuse. By checking bloodwork regularly, the likelihood of undetected liver toxicity is greatly reduced. It is important to note that liver toxicity can be severe due to Antabuse and can even be fatal in some rare cases. For these reasons it is important to notify your doctor if you experience symptoms that may suggest liver toxicity, including dark urine, abdominal pain, or yellowing skin or eyes. Other rare, potentially serious side effects of Antabuse include visual changes and numbness or tingling in arms or legs.
It is generally considered safe to take Antabuse for a long time as long as appropriate monitoring is occurring and the person taking the medication is informed and made aware to notify his or her doctor if he or she experiences any potential side effects.
There are rumors that taking antabuse can be dangerous, especially if you drink on it. How “dangerous” is it? Are you at risk for heart attack and other life threatening events if you drink on antabuse?
Antabuse works because it causes an unpleasant reaction if you drink while having Antabuse in your system. Generally the anticipation of this reaction is what keeps people from drinking. If one does drink on Antabuse, some of the most common reactions include skin flushing, sweating, nausea, and severe vomiting. Also common are sweating, racing heart beat, confusion, and lightheadedness. This very uncomfortable experience generally stops a person from continuing to drink. The reaction is generally uncomfortable, but not dangerous, and resolves once the alcohol is out of one’s system again.
If one consumes a large amount of alcohol and/or continues to drink despite these effects, the reaction can become more severe. Such effects include severe chest pain radiating to one’s jaw or shoulder, slow heart rate, seizure, and slow breathing (or ultimately no breathing). So yes, an Antabuse-alcohol reaction can be fatal, however this is very rare. In fact, if one feels that he or she is likely to continue to drink while on Antabuse, despite the discomfort, then he or she is not a good candidate for Antabuse.
How long does Antabuse last in your system?
A person on daily Antabuse can have a toxic reaction to ingestion of alcohol as far out as two weeks after the last Antabuse use.
What’s the difference between Antabuse and the other medications like Naltrexone and Topamax? How would someone decide which one they should be on, and are some people on both? Do you become dependent on any of these medications if you take them for a while?
The crucial difference between Antabuse and the other medications is that Antabuse acts by making one sick if they drink alcohol while the other medications act by reducing cravings for alcohol. I explained how Antabuse works in detail above. I can best answer this question by now describing a bit about how the other medications work and how I may choose which to prescribe for whom.
Naltrexone works by blocking the main opioid receptors. In this way it reduces alcohol cravings, likely because the main opioid receptor is one of several receptors that alcohol acts on. Some patients on naltrexone have described to me that they have decreased interest in drinking and a decreased desire to continue drinking once they have had a drink. Naltrexone is available as a pill taken once per day or as an injection, known by the brand name Vivitrol, administered once per month by a physician. For people who are also trying to stop using opioids, naltrexone is certainly a good choice. On the other hand, it is not an option for people who are being prescribed opioid medications for pain. The fact that it is taken as one pill, once daily (as opposed to other medications that might require multiple daily doses) makes it a good choice for people who may forget to take medications on a more complicated regimen. The Vivitrol injectable form is a good choice for people who may forget to take their medication or stop it for any reason.
Topamax can reduce cravings as well. It works primarily by increasing activity of an enzyme called GABA. Among other potential side effects, it may also cause appetite suppression and weight loss and can be a good choice in people who would also benefit from these effects. On the other hand, one potential negative effect is confusion/memory disturbance. Also, as opposed to naltrexone which can be started at a therapeutic dose, Topamax must be started at a low dose and then gradually increased over several weeks to achieve the appropriate working dose.
As with these two medications, the other medications noted above also have their varying side effects, dosing intervals, and other factors that differentiate themselves from each other. A prescribing physician can sort through all of this with an interested person to help determine the best choice for that particular patient. Some people do take more than one of these medications at the same time, and benefit from both as they all work through different mechanisms. None of these medications cause physiological dependence. There would be no withdrawal associated with stopping any of these medications abruptly. That being said, you should not stop any prescribed medications abruptly on your own, without discussing with your prescribing physician.
I should note also that while all of these medications have shown efficacy in the treatment of alcohol use disorders, the only three that are FDA approved for such treatment are Antabuse, naltrexone (including the injectable form, Vivitrol), and acamprosate.
Who can prescribe these medications? And do they work as a stand-alone solution to alcohol abuse issues?
Any licensed physician can prescribe these medications. It is best to seek such treatment from a doctor who has expertise and a high degree of comfort treating disorders of alcohol use, such as an addiction psychiatrist or other addictionologist.
These medications do not work as and are not intended to serve as stand-alone treatments for alcohol use disorders. They should be considered only as aids to help a person who is in treatment for their alcohol use disorder. They work best in combination with psychotherapy, which may consist of any combination of individual and/or group psychotherapy as well as self-help groups (12 Step groups and/or SMART Recovery).
Where should people look if they want more information on this?
Consulting with an addiction psychiatrist would be the best way to get questions answered specific to one’s situation, by someone who can appropriately interpret the information. The American Academy of Addiction Psychiatry website (www.aaap.org) has a physician locator that is a good resource for finding a treatment provider.
Also, two government agencies that contain very useful information are The National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov) and The Substance Abuse and Mental Health Services Administration (www.samhsa.gov).