Behavioral treatments aim to change drinking behavior through. They are led by health professionals and backed by studies that show that they can be beneficial. Switch to Chrome, Edge, Firefox or Safari Also visit the online treatment locator. What is the SAMHSA National Helpline? What are the hours of operation? English and Spanish are available if you select the option to speak with a national representative.
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Trained information specialists answer calls, transfer callers to state services or other appropriate intake centers in their states, and connect them to local assistance and support. Alcohol and Drug Addiction Happens in Best Families Describe how alcohol and drug addiction affects the whole family. Explains how substance abuse treatment works, how family interventions can be a first step to recovery, and how to help children from families affected by alcohol and drug abuse. For additional resources, visit the SAMHSA store.
Visit SAMHSA's Facebook Page Visit SAMHSA on Twitter Visit SAMHSA's YouTube Channel Visit SAMHSA on LinkedIn Visit SAMHSA on Instagram SAMHSA Blog SAMHSA's mission is to reduce the impact of substance abuse and mental illness on communities across the United States. This means that it lasts a long time or causes problems over and over again. The main treatment for alcoholism is to stop drinking alcohol. Most people who are alcoholics still feel a strong desire to drink alcohol even after they stop drinking.
A more recent article on drugs for alcohol use disorder is available. WILLIAMS DOCTORATE D. Disulfiram, an aversive agent that has been used for more than 40 years, has significant adverse effects and compliance difficulties with no clear evidence that it increases withdrawal rates, decreases relapse rates, or reduces cravings. In contrast, naltrexone, an anti-cravings agent, reduces relapse rates and cravings and increases withdrawal rates.
Acamprosate also reduces relapse rates and increases abstinence rates. Serotonergic and anticonvulsant agents promise to play a greater role in the treatment of alcohol dependence. Although it is not approved by the U.S. UU.
Food and Drug Administration for this indication, the anticonvulsant topiramate and several serotonergic agents (e.g. Naltrexone (Trexan) and Acamprosate (Campral) are recommended as FDA-approved options for the treatment of alcohol dependence along with behavioral therapy. Disulfiram (Antabuse) does not increase withdrawal rates or decrease relapse rates or cravings compared to placebo, and is not recommended for routine use in primary care. Fluoxetine (Prozac) and other SSRIs are recommended for patients with comorbid depressive disorders.
Topiramate (Topamax) and ondansetron (Zofran) are recommended to reduce the frequency of alcohol consumption and increase withdrawal. Food and Drug Administration; SSRI %3D Selective Serotonin Reuptake Inhibitor. To date, three drugs disulfiram (Antabuse), naltrexone (Trexan) and acamprosate (Campral) have been approved by the U.S. UU.
(FDA) for the treatment of alcohol dependence, and only about 20 percent of eligible patients receive them. However, over the past decade, there has been a growing body of evidence supporting a more central role for medications in the treatment of alcohol dependence. These drugs, the evidence supporting them and the recommended doses are discussed below. Table 13.4 provides a summary of medications with prescribing information, adverse effects, contraindications and costs.
Diarrhea, headache, flatulence, nausea, vomiting, dyspepsia To avoid adverse gastrointestinal effects, the starting dose is usually half the dose given with an increase of one tablet to the daily dose each week. Start with 250 mg once daily; increase to 500 mg once daily. Psychosis due to alcohol consumption, metronidazole (Flagyl) or paraldehyde; cardiovascular disease It starts only after the patient has abstained from alcohol for at least 12 hours. It is generally not recommended to treat alcohol dependence in the primary care setting.
The patient must carry an identification card describing the disulfiram—alcohol interaction. Monitor liver function tests for hepatotoxicity. Start with 20 mg daily; may increase to 60 mg daily as needed. Nausea, headache, sedation, anxiety, sexual dysfunction Use of an MAOI, mesoridazine (Serentil) or thioridazine (Mellaril) Recommended only in patients with comorbid depression Available only as an injection (out of research) to treat opioid overdose.
Nausea, tachycardia, vasodilation, dizziness, headache, chills, vomiting Nausea, headache, anxiety, sedation Use of narcotics, acute opioid withdrawal, acute hepatitis, liver failure General malaise, fatigue, headache, dizziness, anxiety Start with the morning dose of 25 mg and increase to a total of 300 mg administered twice daily in divided doses. Recent FDA Warning on Metabolic Acidosis, Especially with Kidney or Liver Disease Consider Interactions with Other Anticonvulsant Drugs. Dizziness, somnolence, ataxia, impaired concentration, confusion, fatigue, paresthesia, speech difficulties, diplopia, nausea FDA %3D U, S. Food and Drug Administration; MAO% monoamine oxidase inhibitor 3D.
Naltrexone is an opioid receptor antagonist approved for use in the treatment of alcohol dependence along with psychosocial interventions. Naltrexone is believed to act through its blocking of μopioid receptors, which reduces the reinforcing effects of alcohol, leading to a decrease in the feeling of intoxication and fewer cravings. Newer Randomized Controlled Trials (RCTs) Analyzing Longer-Term Outcomes Report Mixed Outcomes. In a systematic review6 of three studies that evaluated medium-term outcomes (six to 12 months), researchers found no difference between the naltrexone and placebo groups.
In addition, in a large trial7 comparing the results of three therapy groups (12 months of treatment with naltrexone, three months of naltrexone followed by nine months of placebo) and 12 months of placebo, there were no significant differences between the groups in the number of days to relapse, the number of days of alcohol consumption or the number of drinks per day of drinking. While there is strong evidence to support the short-term benefit of naltrexone, the evidence for long-term use is less convincing. The recommended dose of naltrexone is 50 mg daily in a single dose. Long-term opioid therapy for chronic pain or heroin dependence is a contraindication for naltrexone because the drug could precipitate withdrawal syndrome.
Naltrexone has been shown to have dose-related hepatotoxicity, although this usually occurs at higher doses than recommended for the treatment of alcohol dependence. The drug is also contraindicated in patients with hepatitis or hepatic impairment, and all patients must undergo monthly monitoring of liver transaminase levels for the first three months and, thereafter, every three months. 8 Disulfiram inhibits acetaldehyde dehydrogenase. Although it has been used to treat alcohol dependence for more than 40 years, evidence of its effectiveness is weak.
An evidence report from the Agency for Health-Care Research and Quality6 concluded that studies using the disulfiram implant show serious methodological weaknesses (more substantially, with regard to the issue of bioavailability), and that the four placebo-controlled RCTs using oral disulfiram results mixed. Although two trials showed that oral disulfiram reduced the frequency of drinking days, it did not improve relapse rates compared to placebo. Two studies looked at patient compliance with oral disulfiram and showed that it was low, and a third study had a 46 percent drop-out rate. These methodological limitations and mixed results make it difficult to clearly establish how many patients benefit from disulfiram.
Disulfiram is usually given at a dose of 250 mg per day with a maximum dose of 500 mg per day. Drinking alcohol after taking disulfiram causes symptoms such as palpitations, hot flashes, nausea, vomiting, and headache. More serious reactions may include myocardial infarction, congestive heart failure, respiratory depression and death. Due to the possibility of a severe interaction between alcohol and disulfiram, disulfiram is contraindicated in patients who receive or have recently received metronidazole or who have ingested alcohol, psychosis or cardiovascular diseases, and is not recommended for patients with severe lung disease, chronic renal failure or diabetes, or people over 60 years of age.
It is also not recommended in patients with peripheral neuropathy, convulsions or cirrhosis with portal hypertension. Hepatotoxicity is a rare but potentially fatal side effect. 8 Some experts recommend that baseline liver function tests be performed, with repeat tests at two weeks, three months, six months and, thereafter, every six months. Because of these significant restrictions and compliance issues, disulfiram is not recommended for treating alcohol dependence, particularly in the primary care setting.
6 Disulfiram is FDA pregnancy category C. Acamprosate (calcium homotaurinate) is believed to block glutaminergic N-methyl-daspartate receptors and activate 3-aminobutyric acid type A receptors, and was recently approved by the FDA for the treatment of alcohol dependence. A systematic review10 of 15 studies showed that acamprosate reduces short-term and long-term relapse rates (more than six months) in patients with alcohol dependence when combined with psychosocial treatments. The results in favor of acamprosate included fewer patients who returned to drinking (68 vs 80 percent, NNT %3D) and a higher percentage of total abstinence days (54 vs 38 percent, NNT %3D).
A clinical trial12 of 101 patients showed that fluoxetine (Prozac) at doses up to 60 mg per day did not have a significant effect on alcohol consumption in alcohol-dependent people without major depression. In a study13 involving psychiatric patients with major depression and alcohol dependence, those treated with 20 to 40 mg per day of fluoxetine for 12 weeks consumed fewer drinks, fewer days of drinking and fewer days of heavy drinking than those receiving placebo. Other SSRIs have shown similar results 14. Studies on the effect of SSRIs on patients with more severe alcohol dependence (type B according to the Babor and colleagues classification system1) do not show clear benefits and sometimes show trends towards worse outcomes with SSRIS,16 and studies involving patients with less severe alcohol dependence (Babor Type A1) do not show consistent benefits, 17 The use of selective serotonin antagonists for early alcohol dependence has also been investigated, with positive results. In a RCT, ondansetron (Zofran) was shown to significantly reduce self-reported alcohol consumption.
Patients who received ondansetron 4 mcg per kg twice daily drank fewer drinks per day. They also had a higher percentage of abstinence days (70 versus 50 percent on placebo) and a higher total number of abstinence days per study week (6.7 vs 5.9 with placebo) in patients with early-onset alcoholism. All patients also received weekly group cognitive behavioral therapy. Recent research suggests a role for anticonvulsants in the treatment of alcohol dependence beyond their use in withdrawal syndromes, 4 Topiramate (Topamax) inhibits the release of mesocorticolimbic dopamine, which is thought to be associated with the desire to consume alcohol.
It is the best-studied drug in its class, although gabapentin (Neurontin), 19 and valproate (Depacon), 20, have shown promise in case studies and small trials. In a 12-week double-blind RCT4 of patients with alcohol dependence who are actively drinking, topiramate was more effective than placebo in initiating abstinence (26 percent more days of abstinence with topiramate) and in reducing self-reported drinks per day, drinks per day of alcohol consumption, and days of alcohol consumption excessive consumption of alcohol. Compared to placebo, it also significantly reduced the desire to drink as measured on an obsessive compulsive consumption scale. These findings occurred in patients with early-onset and late-onset alcoholism.
The study4 used an increasing dose of 25 to 300 mg of topiramate per day. Hypersensitivity to the drug is the only known contraindication. Adverse effects include dizziness and somnolence (which are not dose-related), ataxia, impaired concentration, confusion, fatigue, paresthesia, difficulty speaking, diplopia, and nausea. There are interactions between topiramate and other anticonvulsants, such as phenytoin, valproic acid (Depakene) and carbamazepine (Tegretol).
Nalmefene (Revex), another opioid antagonist, is similar to naltrexone but without FDA approval for the treatment of alcohol dependence. Nalmefene in doses of 20 or 80 mg orally daily in an RCT21 has been shown to significantly reduce relapse to excessive alcohol consumption in outpatients with alcohol dependence. Patients receiving nalmefene had a relapse rate of 37 percent compared to 59 percent in the placebo group (NNT %3D). However, treatment groups did not differ significantly in the percentage of abstinence days, the average number of drinks consumed on a drinking day, or in self-reported craving ratings.
This 12-week study21 also provided weekly cognitive behavioral therapy to all groups. Outside of research, nalmefene is only available in injectable form. The best options for relapse prevention are acamprosate and naltrexone with simultaneous counseling through professional or self-help programs. Family physicians may also consider using an SSRI in the presence of a comorbid mood disorder.
Evidence of combination drug therapy is lacking, but research is underway. Topiramate and ondansetron hold promise as treatments to increase withdrawal. Due to its lack of effectiveness and problems with adverse effects and compliance, disulfiram is not recommended for use in the primary care setting. Already a member or subscriber? Are you interested in becoming a member of the AAFP? More information STEVEN H.
Williams received a doctorate in counseling psychology from the University of Florida, Gainesville, and a postdoctoral certification in psychopharmacology from Fairleigh Dickinson University, Teaneck, N, J. Access the latest issue of American Family Physician. Patients may also receive different medications while in the care of an addiction treatment professional to help treat symptoms of co-occurring disorders if needed. For specialty addiction treatment options, contact your doctor, health insurance plan, local health department, or employee assistance program.