Her husband was no alcoholic, but the wife thought he drank too much: a bottle of wine each night instead of a glass or two. When they went to see Mark Willenbring, MD, founder and CEO of Alltyr, an addiction treatment center in St. Paul, Minnesota, he diagnosed the husband with mild alcohol abuse and prescribed naltrexone.
“It’s a buzz kill, and of course we go for abstinence with severe alcoholics, but we got this guy to cut down,” said Dr. Willenbring, former head of treatment and research at the National Institute of Alcohol Abuse and Alcoholism (NIAAA). “That still counts as success, for the patient and the community.”
Reducing Heavy Drinking With the Right Drug
Willenbring joins other alcohol addiction doctors and national policymakers who’ve expanded their goal of abstinence to include reducing heavy drinking. New research shows that naltrexone, among three drugs approved by the U.S. Food and Drug Administration for alcohol relapse prevention, can increase sober days of current drinkers.
“When medication is used for alcohol disorder, we suggest first-line treatment with naltrexone for most patients over other medications,” researchers concluded in the December 2014 study. Other drugs may be as useful, including acamprosate, for maintaining abstinence, “while naltrexone was more effective for reduction of heavy drinking,” the study authors wrote.
Acamprosate can curb withdrawal symptoms or cravings, but it also helps rebalance a person’s brain chemistry, which can be altered by heavy or long-term drinking. It’s not harmful if someone drinks after taking it, but it hasn’t worked for those currently drinking. Disulfuram prevents the body from metabolizing alcohol, triggering severe vomiting, nausea and headaches, which may deter drinking.
After two decades, doctors still seldom recommend medications because they aren’t aware of them or have outdated beliefs that all of these drugs cause disulfuram’s miserable side effects for those who drink alcohol. Naltrexone causes no such illness, but blocks the brain’s pleasure receptor, removing alcohol’s feeling of reward. Willenbring says naltrexone can make it easier to drink less — it can be taken as needed and you know as soon as you drink whether it’s working or not: You get a buzz or you don’t.
Research shows that naltrexone works best for Caucasians and is the least effective for African-Americans. People of Asian or Hispanic origin have yet to be adequately studied. Naltrexone’s been shown to work especially well for people of Scandinavian and Northern European descent simply due to a gene mutation, says George Koob, PhD, a neurobiologist and head of the NIAAA. The national agency is directing the effort to develop new drugs for treating the full range of alcohol use disorder, from mild to severely dependent.
Who’s Drinking Enough to Warrant Drug Treatment?
While the World Health Organization estimates that 75 million people globally had alcohol abuse or dependence in the prior year, recent U.S. government findings show that most drinkers aren’t addicted: Only 1 percent is dependent or severe alcoholics. Another 3 percent are considered functioning alcoholics, because they continue to work while few recognize their alcohol problem.
A larger group has a full range of alcohol use or abuse that requires very personalized treatment. Yet 30 percent of U.S. adults reported drinking more than the daily recommended limit of four drinks for men and three drinks for women.
Recognizing that only 10 percent of people with alcohol use disorder ever get treatment — and those are mainly sufferers of severe alcohol use disorder — addiction treatment doctors are weighing any potential approach. “The goal is abstinence, but where you end up is fine, and we’re happy with a reduction in drinking,” Dr. Koob says. “To some extent, this is a shift in policy.”
Maine’s Quest for New Approaches to Fight Alcohol and Drug Addiction
A statewide initiative in Maine has enlisted teams from medical professionals on the front lines of treatment to tackle its substantial addiction problem, particularly dependence on prescription painkillers. A key project: rapidly reaching primary care doctors, nurses and other non-addiction specialists with a method to better screen patients for substance abuse. A brochure, part of a broad education program called Time to Ask, is hoped to effectively work as a script for the right words in what’s usually an uncomfortable conversation, says Noah Nesin, MD, FAAFP, chief medical officer of Penobscot Community Health Center.
“These medicines are easy to prescribe,” says Dr. Nesin, a member of Lunder-Dineen Health Education Alliance of Maine, which is avidly seeking out new approaches. “Naltrexone is moderately successful, offering a 15 to 25 percent reduction in heavy-drinking days and a more modest increase in sober days,” he says. “The more approaches we have, the better. We’re trying to increase abstinence levels, but total and permanent abstinence doesn’t have to be the only definition of successful.”
By Nancy Wride
Follow Nancy on Twitter at @NWride