Medications
Helping stop the cravings
Anti-addiction medicines are important for the treatment of drug and alcohol addiction for your loved one for many reasons. Since drug and alcohol addiction is a chronic disease that begins in the brain, Enterhealth Ranch and Enterhealth Outpatient Center of Excellence utilize anti addiction drugs as a critical element of a comprehensive treatment plan personalized for each patient. Due to the powerful chemical changes that occur in the brain as the result of the injury from alcohol or drugs, cravings from deep inside the center of the brain drive each person to use, often overwhelming even the strongest logic and desire to quit.
Fortunately, amazing breakthroughs in drug and alcohol addiction treatment and medical scientific research have greatly facilitated long-term, successful sobriety by utilizing specific FDA-approved medications to shut down cravings in the brain.
A critical element in supporting recovery
As part of a comprehensive and personalized treatment plan, anti addiction drugs can help with the unpleasant drug and alcohol withdrawal symptoms and stop the cravings in order to promote healing.
The FDA approved Vivitrol in June 2006 for the treatment of alcohol dependence or alcoholism (as well as for the treatment of opioid addiction, heroin addiction and pain pill addiction in 2010). Vivitrol is an injection that is received in the gluteal (buttock) muscle once a month. During that one-month period, a medication called naltrexone is slowly released into the bloodstream.
Overview of Vivitrol and its benefits:
Vivitrol (naltrexone) is a safe and effective medication that helps prevent relapse to alcohol and opioids by doing three main things:
- It decreases cravings by as much as 90%.
- In those who do drink or use opiates on Vivitrol, it effectively prevents them from getting drunk or high.
- It provides an uninterrupted dose for a month at a time thanks to its long-acting formulation.
Suboxone is the first opioid (narcotic) medication approved for the treatment of opioid addiction in an office-based setting. Suboxone also can be dispensed for “at-home” use, just as any other medicine for other medical conditions. The primary active ingredient in Suboxone is buprenorphine. Initially developed to treat pain, buprenorphine was adapted for use in treating opioid addiction in cooperation with the National Institute of Drug Abuse (NIDA) and was approved by the FDA in October 2002.
Overview of Suboxone and its Benefits:
Suboxone (Buprenorphine) is used to reduce illegal opioid use and to help patients stay in treatment by blocking the effects of opioids, decreasing cravings, and suppressing any major symptoms of withdrawal. Most narcotic addicts seem to benefit from Suboxone regardless of their histories of opiate addiction.
Suboxone is safe, effective, and is a revolutionary step in the treatment of narcotic addiction. It can be easily used in both the withdrawal stabilization (detoxification) and maintenance phases of opiate addiction treatment. Also, because of its ease of use and excellent safety profile, its use by the growing number of primary care physicians who are screening for and recognizing narcotic addiction in their practice populations should make a very positive impact in the treatment success rates for narcotic addicts.
Campral (generic name: Acamprosate), a medication widely used in Europe since the late 1980s to reduce alcohol cravings in alcoholics who have quit, was approved by the U.S. Food and Drug Administration in 2004 to treat alcohol dependence in the United States.
Although the precise mechanism of action or “cellular target” of Campral is unknown, it appears to decrease cravings primarily by restoring the balance in certain neurotransmitter pathways (most likely GABA + Glutamate) that have become altered by chronic alcohol abuse.
The GABA neurotransmitter system in the brain is a very important control system that is responsible for “calming you down” and helping you to relax. Because it calms you down, it is referred to as an “inhibitory” system. The Glutamate neurotransmitter system in the brain is just as important as the GABA system, but it has the opposite effect on the body: it causes you to get energized (referred to as your “excitatory” system).
Another way to look at these two important systems is to take an analogy of a car. The GABA system is like your brakes, allowing you to slow down, while the Glutamate system acts like the accelerator. If you have a car with only one system or the other, it is not a very functional car – you need both systems to balance each other out in order to be able to use the car effectively.
So, when anyone drinks alcohol (not just an alcoholic, but anyone), Campral stimulates the GABA system in the brain and the person becomes sedated and relaxed (the brakes slow you down). At the same time, the Glutamate system is suppressed (so the accelerator is not being pressed). When the alcohol wears off, your excitatory system “rebounds” and you feel more irritable, agitated, and may find it difficult to sleep (remember: the brakes are now off and the accelerator is being pushed).
Now, if you are an alcoholic, you have been drinking regularly in most cases and you develop tolerance – meaning you require more alcohol to achieve the same effect. What tolerance basically does to the GABA/Glutamate systems is that it modifies both in some respect. But, at the end of the day, an alcoholic must consume more alcohol to “put on the brakes” (slow down and relax). Then when the alcohol wears off, the Glutamate system has become somewhat “turbocharged” and the result is that the accelerator seems to be “pressed to the floor” resulting in quite severe withdrawal symptoms in many cases.
Alcohol Withdrawal Symptoms
If you think about it, alcohol withdrawal symptoms are the result of many body systems being stimulated – blood pressure and heart rate are increased, and the drinker is irritable and has difficulty calming down or going to sleep. Even after the first 5-6 days of alcohol withdrawal have passed and the more severe withdrawal symptoms have gone away, the Glutamate system still seems to be “overly active” and the GABA system still seems to underperform. The result is the “post-acute” alcohol withdrawal phase, when the alcoholic remains irritable at times, has persistent insomnia, and has difficulty concentrating, which are all symptoms of a hyperactive accelerator and somewhat “weak brakes.”
Thankfully, in the “post-acute” alcohol withdrawal phase, these symptoms are only intermittent. Recovering alcoholics feel fine at times, but during periods of stress, they seem to get “extra hyper.” It is during these “extra hyper” times that they experience some combination of these symptoms, which then can produce alcohol cravings, which then can increase the chance of a slip or even a full relapse.
What Campral appears to do (after a 4-6 week period of taking it on a daily basis) is restore the normal balance of the GABA/Glutamate interaction. In other words, it seems to begin to restore the brake system and accelerator back to their normal functioning levels. Consequently, alcohol addiction patients on Campral report (after the first 4-6 weeks of being on it) they begin to feel calmer, can handle stress more effectively, are able to concentrate and focus better, as well as have decreased cravings or desire for alcohol.
Unfortunately, these significant improvements for the alcoholic patient take at least a month to begin to appear. Sometimes it is very hard for alcoholic patients to wait that long because they are so accustomed to “instant gratification” that they get impatient and stop the anti-addiction medication prematurely. Also, when the positive effects appear, they usually develop slowly over 2-4 weeks and so there is no overt, pronounced effect. But one day, 6-10 weeks after starting the Campral, alcoholic patients report they notice they are just “a lot better,” are more relaxed, sleeping better, and have significantly reduced alcoholic cravings.
Once the alcoholic patient is convinced to take Campral with the above facts and reasoning, in combination with a medical evaluation by an addiction specialist, the next challenge with Campral is actually taking the medication. Unfortunately, Campral is not well absorbed by the body’s gastro-intestinal tract. In fact, only 10% of each pill is absorbed. So, in order to get the 200mg/day of Campral into the patient’s bloodstream that is needed to begin healing the GABA/Glutamate systems, the patient needs to take six tablets per day (1998 mg) for the medication to work. Addiction patients usually take 2 tablets 3 times a day, but it is difficult for anyone to take any medication 3 times a day without forgetting that middle-of-the-day dose. Therefore, Enterhealth usually prescribes 2 tablets 3 times a day for the first 2 weeks and then changes to taking 3 tablets twice a day thereafter, not requiring patients to take the lunchtime or mid-day doses.
A related issue that comes up for some addiction patients is they say, “Doctor, I don’t want to take 6 tablets each day. That is too much medication. I don’t want to put anything in my body that will hurt me or, I don’t want to get addicted to Campral.” Obviously, these arguments are ludicrous as this anti-addiction medication will give them a great chance to stop using alcohol – a very toxic substance that is already killing them. Also, Campral is not toxic at all to the body and, like Vivitrol or naltrexone, it is not addicting nor can it be abused. Also, once most patients understand the poor absorption of Campral is the reason that they have to take 6 pills a day, they usually do not mind taking that many pills a day.
Finally, some alcoholics are resistant to taking medication to help them because they are not truly committed to stopping alcohol. Regardless, they can be strongly encouraged (and required, if possible) to take the medications and then encouraged to work through their ambivalent feelings about starting in a treatment program and/or attending AA meetings while the medication is starting to help them feel better. Remember, Campral, just like any other addiction medications, needs to be taken as one part of a comprehensive addiction treatment plan.
Fortunately, the side effects of Campral, like Vivitrol, are minimal. The main one is diarrhea, and this is quite infrequent, especially after the first 1-3 days of taking it. If diarrhea does occur, over-the-counter medications, such as Imodium, are very effective. Other even less common side effects are nausea, itching and intestinal gas. Also, Campral, like Vivitrol, does not interact with other medications, so it can be added to just about any current medication regimen without concern, as long as the patient’s doctor is aware of all medical conditions and other medications the patient is taking.
Most patients stay on Campral for at least a year and a half and then, depending on how they are doing in their recovery program, they and their physician can consider and discuss discontinuing it.
From a scientific standpoint, 14 out of 16 controlled clinical trials in European countries have demonstrated evidence for its effectiveness, showing that acamprosate-treated patients have a significantly greater rate of treatment completion, time to first drink, and abstinence rates than patients treated with a placebo.
Disulfiram (Antabuse®), a sensitizing or deterrent agent, was approved by the FDA for the treatment of alcoholism in 1951. It has been used as an aid in managing chronic alcoholic patients who want to remain in a state of enforced sobriety so that they can participate in residential, outpatient treatment and 12-step programs effectively.
Disulfiram produces sensitivity to alcohol that results in a highly unpleasant reaction when the patient taking it drinks even small amounts. It does this by interfering in the alcohol enzymatic metabolism (breakdown) pathway resulting in an accumulation of a chemical (acetaldehyde) in the blood. This toxic by-product of normal alcohol metabolism produces a complex of highly unpleasant symptoms, including intense nausea and vomiting, sweating, flushed skin, throbbing headache, respiratory difficulties, blurred vision and confusion.
Antabuse has a valid place as an integral part of certain recovery programs. However, because of its toxic reactions, it does have some safety issues – although they are much less concerning than the safety issues related to continued alcohol use. Because of these safety issues, it is not typically used as a first-line treatment for alcoholism anymore. Rather, it is a medication to be used only if all other standard treatments fail, or it can be added to other pharmacological strategies, such as adding it to Vivitrol/Campral or Campral by itself.
When Antabuse is used, it is very important that it is given to the patient under a monitoring situation. The patient needs to be watched while taking it each morning, and the patient’s mouth should be orally inspected after swallowing each tablet to ensure compliance. If the compliance is ensured via a visual monitoring (observation) program, Antabuse can be very effective when used as a component of a comprehensive addiction treatment program.
Unlike Campral, however, Antabuse acts only as a deterrent; it does not heal any of the damage caused by the alcoholism. The usual dose of Antabuse is 250 mg/day, and liver function blood tests should be obtained by the patient’s primary care physician on a quarterly basis (4 times/year).
One of the complications of taking Antabuse is that it can cause the typical toxic reaction even with very small amounts of alcohol, even if they are taken accidentally. Consequently, a patient on Antabuse has to be very careful to not use certain alcohol-containing products (such as perfume, mouthwash) or to use them very carefully. Also, certain sauces for food can contain small amounts of alcohol and cause a reaction. However, if the patient is carefully observant of their environment, these hazards can be easily avoided.