Feb 20 2005
A little-known drug called naltrexone provides a “meaningful benefit” in helping alcoholics moderate their drinking, according to the latest review of evidence from 29 studies on four continents.
The findings, along with the recent FDA approval of a similar drug called acamprosate, open the door to new treatment options for drinkers who aren’t yet ready to face total abstinence.
Naltrexone, which is not addictive, “should be accepted as a short-term treatment for alcoholism,” say authors Dr. Manit Srisurapanont and Dr. Ngamwong Jarusuraisin of Thailand’s Chiang Mai University. Almost all of the studies tested naltrexone, or NTX, in combination with psychosocial treatments such as counseling or self-help groups, and the authors recommend using this approach in everyday practice.
The review’s conclusions are based on “high-quality evidence” that naltrexone reduces by 36 percent the risk of an alcoholic relapsing to heavy drinking in the first three months of recovery. “Short-term treatment of NTX for alcoholism gives a meaningful benefit in preventing a relapse,” the review said, citing an 18 percent lower likelihood that patients will abandon their treatment program.
The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
Dr. Joseph Volpicelli, of the University of Pennsylvania School of Medicine, has been conducting research on naltrexone use for alcohol dependence since the early 1980s. Naltrexone blocks the brain’s receptors for natural painkillers, known as opioids, which normally create the feeling of wellbeing associated with drinking.
He explains that the benefits of naltrexone lie not so much in preventing a patient from having one drink, but rather in breaking the cycle where one drink leads to many more. “Naltrexone helps people have more control over the use of alcohol. For me, that’s the fundamental issue of what addiction is: impaired control.”
However, this approach requires a substantial change from the abstinence-only philosophy that goes back at least as far as Prohibition. Naltrexone is most effective, says Volpicelli, in a treatment program “designed to support the notion that while one drink is not great, what you really want to stop is excessive drinking.”
While few professionals advise people with alcoholism to abandon the ultimate goal of total abstinence, Volpicelli argues that about 20 million Americans suffer from alcohol abuse disorders, yet only about 2 million are in any kind of treatment program. “We should be flexible enough to get at that 90 percent of people who aren’t in treatment,” he says.
The U.S. Substance Abuse and Mental Health Services Administration agrees in its naltrexone treatment protocol, saying, “Abstinence should be a desired goal for the patient; however, reductions in drinking may be an acceptable intermediate outcome … because there are many other areas of a patient’s life that can improve, such as job performance, social relationships, and general physical health.”
Although naltrexone (ReVia) has been available for more than 10 years, Volpicelli says it has been poorly marketed, and most patients and primary care doctors remain unaware of its potential. That may change now that the manufacturer of acamprosate (Campral) has embarked on a campaign to promote pharmacological treatment of alcohol addiction.
Review author Srisurapanont notes that the availability of both medicines now gives patients an alternative if one is not effective for them. And, he adds, the possible benefits of using the medications in combination should be studied. The review also notes that other areas ripe for future study include the possible benefit of continuing naltrexone treatment beyond the first three months of recovery and strategies to further increase treatment completion.
Volpicelli believes psychiatry is on the brink of recognizing a new standard of care for alcohol abuse disorders: allowing patients to choose from a variety of treatments, which may or many not focus on total abstinence. It is, he believes, a time of great hope. To those who suffer with alcoholism, he says, “Be aware of all the options available and find the best one for you. See someone, stay in treatment, and over time you’re going to get better.”