As indicated in my previous article, based on the comprehensive 2014 Journal of the American Medical Association (JAMA) report on medications for alcohol use disorders (AUDs), I indicated that this column would address why its findings may be a bit misleading when it comes to practice. We’ll look at some practical insights from clinicians who use these medications with patients and what some people who have tried them have to say.
The JAMA “study of studies” was based largely on a research design called a “meta-analysis,” which is a quantifiable way of assessing previous research to arrive at conclusions about a body of research on a particular topic. It’s a way of coming up with a consolidated, statistical review of a large, often complex, and sometimes conflicting, body of studies on that topic. While we often turn to meta-analyses for “the answers” to particular issues, their conclusions can be misleading and there may be caveats to bear in mind when it comes to applying the findings in the real world.
Real-World Use of Medications for Alcohol Use Disorders
While the JAMA report concluded the medication, acamprosate, is one of the most effective FDA-approved medications for AUD, a number of seasoned clinicians told me that they do not find it to be particularly beneficial.
“Most of my colleagues who see a lot of patients agree that [acamprosate] isn’t very effective. Being so dependent upon meta-analyses not infrequently misses the mark completely.”-Dr. Mark WillenbringMark Willenbring, M.D., founder and CEO of Alltyr clinic in St. Paul, Minnesota and former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism, noted that all of the recent large, high-quality studies for acamprosate were negative. Dr. Willenbring explained, “Most of my colleagues who see a lot of patients agree that it isn’t very effective. Being so dependent upon meta-analyses not infrequently misses the mark completely.”
Henry Steinberger, Ph.D., a psychologist who specializes in treating substance use disorders in Madison, Wisconsin, said, “I have not found anyone willing to take acamprosate (2 big pills 3 times a day) although I’ve suggested it to many with a craving problem.”
The JAMA report also concluded that there is not adequate evidence supporting efficacy of disulfiram (Antabuse.) However, Dr. Willenbring finds, “When monitored, it’s by far the most successful medication with my clients.” The greatest drawback with disulfiram is getting clients to stick with taking it. By “monitoring” Dr. Willenbring is referring to the practice of having someone – such as a supportive spouse or professional – see to it that you take the medication as prescribed. (Other experts concurred.) It’s more likely to help if you are also receiving counseling, such as cognitive-behavioral therapy.
Dr. Willenbring also finds that topiramate helps a number of his clients. Topiramate did receive some support in the JAMA report, although less than acamprosate and naltrexone, the two most commonly prescribed meds for AUDs. Fewer studies have been conducted on topiramate, but a 2014 meta-analysis of randomized controlled trials – the gold standard type – comparing topiramate to a placebo for the treatment of AUDs, suggested that it may be somewhat more effective than acamprosate and naltrexone.
Similarly, Jill’s brother, Will F., has found both medications to be helpful. When he first quit drinking, he said, “The disulfiram was definitely helpful. I took it in the morning, when my willpower was strongest. That way, you’ve made your decision for the day.” When he’d try to quit drinking on his own, he found, “I’d regularly wake up in the morning and feel that I wasn’t going to drink that day. But then I’d wind up doing it at night. The disulfiram took away the option.” Of topiramate he found, “It seemed to reduce the urge [to drink] and to balance out my mood. I felt more at peace and less irritable, more at ease with the difficulty, with the task of quitting, less anxiety about it.”
“Most clients are not able to be abstinent over the course of early recovery… We prefer to use naltrexone, which both decreases cravings and helps you drink less if and when you do drink.”-Dr. David SackDavid Sack, M.D., CEO of Elements Behavioral Health, the company that owns Promises Treatment Centers, agreed that acamprosate is not effective for most clients and pointed out that it was tested for abstinence. He said, “Most clients are not able to be abstinent over the course of early recovery – they benefit from treatment but are not ready to commit to abstinence. We prefer to use naltrexone, which both decreases cravings and helps you drink less if and when you do drink.” They’re inclined to use injectable naltrexone for clients with AUDs because you don’t have to think about taking a pill each day, and its effects last for about a month.
Dr. Sack added, “You need a high level of adherence for naltrexone to work. With oral pills, it’s a constant struggle because you have to make a decision every day about whether to take them.” Some Promises physicians are also using topiramate, but typically it’s prescribed for AUDs, plus other psychological problems for which topiramate can be helpful, such as bipolar disorder, and other conditions such as epilepsy.
What Meds Help Which People
Dr. Willenbring pointed out, “There is not yet a way to predict how likely a patient is to respond to one medication rather than another.” He added, “Achieving the goal of ‘personalized’ medicine through the use of biomarkers and pharmacogenomics is the focus of extensive research across medicine.”
However, renowned addiction expert Bankole Johnson, D.Sc., M.D., Ph.D., gave some pointers based on the limited information we do have about individual responses in a comprehensive on-line review of the research on medications for AUDs. He concluded that people most likely to respond to naltrexone include those with a family history of AUDs and strong cravings for alcohol. Those more likely to respond to acamprosate include individuals with increased levels of anxiety, physiological dependence (that is, severe symptoms of withdrawal), negative family history, late age of onset, and female gender.
“Those more likely to respond to acamprosate include individuals with increased levels of anxiety, physiological dependence… negative family history, late age of onset, and female gender.”-Anne Fletcher
It’s interesting that Jill and Will (described above) are brother and sister in light of a study published earlier this year in the American Journal of Psychiatry and conducted at the University of Pennsylvania School of Medicine. The study suggested not only that topiramate appears to be helpful in treating problem drinkers whose goal is to curb their alcohol consumption (previous studies showed it to reduce drinking in people committed to abstinence), but that it may be particularly helpful among a specific group of individuals whose genetic makeup appears to be linked to the efficacy of the medication. (Note, however, that this was a small study.)
“The approved drugs for alcohol use disorders have not been shown to have blockbuster effects in the way that antibiotics do for bacterial infections.”-Dr. Daniel KivlahanOverall, Daniel Kivlahan, Ph.D., who co-wrote the editorial accompanying the recent JAMA report told me, “The approved drugs for alcohol use disorders have not been shown to have blockbuster effects in the way that antibiotics do for bacterial infections.” Such medications are meant to be used as “add-ons” to sound addiction treatment strategies, such as cognitive-behavioral therapy. The editorial noted that the AUD medications were, indeed, added to behavioral counseling interventions in patients who were already abstaining when the medication was started, and that it could be challenging for everyday medical providers to provide this kind of support to their clients. Nevertheless, Dr. Kivlahan believes, “The medications for AUDs do boost the odds of success on average, and some individuals consider them to be a critical tool in their recovery.”
It’s important for consumers to know that they can advocate for themselves by asking their own primary health care providers to prescribe such medications, whether or not they are in formal treatment for an AUD.
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