An introduction from Addiction Professional's
This is the second in a series of six articles designed to provide you with the latest information on the use of medications in alcohol dependence treatment. Medications (pharmacotherapy) used as adjuncts to counseling techniques and biopsychosocial, educational, and spiritual therapies are an increasingly important part of a comprehensive treatment approach for alcohol dependence.
The addiction counseling community needs to understand how these medications are used in order to optimally coordinate care of patients with other treatment providers. Thus, the article series Pharmacotherapy: Integrating New Tools Into Practice will not only provide the latest efficacy and safety data on these medications, it will also explore how we can build better relationships among addiction professionals and medication prescribers. The series will also examine the current barriers to medication use in treatment while offering potential solutions.
The series began in the January/February 2007 issue with an article by Carlo C. DiClemente, PhD, who discussed recovery from alcohol dependence as a process of change and examined how medications might facilitate that process. The series continues with an article by Carlton K. Erickson, PhD, who looks at what some of the most important study results from recent years tell us about the approved medications for alcohol dependence treatment. This article focuses on results for acamprosate, naltrexone, and extended-release naltrexone.
Recent advances in the treatment of alcohol dependence have made this an exciting time for addiction professionals. New studies have given us more options and directions for treatment, including the use of new medications in combination with established therapies. Understanding how best to use this new information in practice is challenging, especially when important questions require additional study. There are four FDA-approved medications for the treatment of alcohol dependence—disulfiram, oral naltrexone, acamprosate, and extended-release injectable naltrexone—with a wealth of literature on their use.
Disulfiram is an older drug with which many clinicians are familiar. Compliance to disulfiram therapy is a common barrier to its use, and clinical trials have shown mixed results with regard to disulfiram's efficacy in supporting abstinence.1 There are few recent studies of disulfiram for alcohol dependence, and new research has focused on its use in treating individuals who are dependent on cocaine.2 Thus, we will not look at the disulfiram literature in this article.
Acamprosate and oral naltrexone have a substantial body of evidence supporting their use for alcohol dependence treatment. For example, a meta-analysis of oral naltrexone studies from approximately the past 10 to 15 years found that oral naltrexone significantly reduces the risk of relapse to heavy drinking by 38% compared with placebo.
3 Acamprosate's approval for use in the United States in 2004 followed extensive study as well as use in Europe and elsewhere. A review of those studies reveals that acamprosate, in comparison with placebo, significantly improves continued abstinence among alcohol-dependent individuals who have stopped drinking.
3,4 Finally, extended-release injectable naltrexone (XR-NTX) is a new injectable formulation of naltrexone approved in 2006. A pivotal trial demonstrated that XR-NTX reduces heavy drinking and may improve abstinence when combined with psychosocial therapy.
Carlton K. Erickson, PhD
Though this article does not review all new studies of FDA-approved medications for alcohol dependence treatment, it highlights some of the most important study results from the last couple of years and suggests how they can be applied to practice.
Two general concepts should be kept in mind as addiction professionals consider new medications: (1) these are not magic bullets that will “cure” addiction, and (2) they require or work best with ongoing counseling or psychosocial therapy.
Acamprosate may reduce the negative symptoms (irritability, anxiety, negative affect) present after acute withdrawal from alcohol by blocking the effects of glutamate, an excitatory neurotransmitter in the brain that may become more active with chronic alcohol use. One of the larger and more recent trials of acamprosate was conducted by Mason and colleagues (2006).4 This study concluded that abstinence-motivated individuals might have better results with acamprosate than those who do not initially strive for abstinence.