April — for T.S. Eliot, “the cruelest month”—has been designated as Alcohol Awareness Month. I will mark it by writing about the surprising paucity of effective medications for treating alcohol use disorders. Highly promoted combinations of substances throughout the 20th Century did not stand the test of time. The use of long-term Valium proved to be detrimental. For withdrawal management, we, fortunately, do have medications that reduce or eliminate the danger and discomfort of that condition. Even those, however, are not officially approved for that purpose by the Food and Drug Administration (FDA).
Relapse prevention is a fundamental strategy for achieving long-term sobriety, and there are a variety of psychosocial interventions that help. Medications to supplement these efforts would be welcome, but currently, only three medications are FDA-approved for treating alcohol use disorders:
- Disulfiram (Antabuse) deters relapses by creating a negative effect if a person drinks after having taken the medication. I have found disulfiram to be the most useful for the broadest group of patients; many of my patients express gratitude for its existence. Its effectiveness is limited, however, by the fact that it only works reliably if its administration is observed, which is not always feasible.
- Naltrexone (Revia, Vivitrol) reduces cravings and also dulls the pleasurable effect of alcohol by blocking the action of endogenous opioids that are released when alcohol enters the brain. It is very effective for patients with a particular genetic makeup, but in my experience most patients do not find it helpful.
- Acamprosate (Campral) reduces the desire to drink by correcting one of the metabolic imbalances in the brain that heavy alcohol intake causes. Positive research studies in Europe created much anticipation in the U.S. Experience in this country, however, has been disappointing once again except for a few individuals who find it to be very beneficial.
Because all three work by different mechanisms, using them in combination is possible. However, research studies do not support the benefit of using more than one simultaneously for treating alcohol use disorders.
Other medications, including topirimate and ondansetron, have shown some promise in early studies, but more research is needed to validate their use. To get a closer look at this hopeful possibility, I have agreed to serve on a committee overseeing research on whether ondansetron can be of help in reducing binge drinking in youth.
I would be interested in your ideas about how to address this puzzling lack of medications for a condition that is so common and has been with us for so long. Please share them by commenting on this post.