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What different kinds of medications are available for alcoholism?

Medications for alcoholism can be divided into several categories: (1) Medications can treat alcohol withdrawal syndromes. These syndromes are medical emergencies and medication is a medical necessity. (2) Medications can treat the underlying psychiatric disorders that may be contributing to though not causing one's alcoholism. (3) Medications or treatments can offer a behavior modification approach. The individual needs to know that if he or she drinks while taking some of the medications he or she will become violently ill. (4) Finally, medications can directly act on the brain to reduce craving or maintain abstinence. The Federal Drug Administration (FDA) has approved only three of these medications specifically for the treatment of alcoholism, whereas all other medications used for the treatment of alcoholism are off-label (i.e., currently not a medication that the FDA approved for that particular use). The three approved are discussed in greater detail in the next three questions. Medications that treat alcohol withdrawal are covered in Question 56 under detox.

Bipolar disorder a mental illness defined by cyclic episodes of mania or hypomania, classically alternating with episodes of depression; however, the condition can take various forms, such as repeated episodes of mania only or only one episode of mania and repeated episodes of depression or rapid cycling between mania and severe depression.

The degree to which individuals and clinicians believe in the importance of taking medications varies with each category. Everyone in the profession understands and agrees that detoxification is a medical problem requiring medication. Most agree that treating underlying psychiatric illnesses such as schizophrenia, bipolar disorder, or depression is necessary, even though the use of these medications can entail some degree of controversy. This is true particularly among those alcoholism specialists who zealously believe that all medication used to modify behavior cause a form of dependency. The use of medications that are prescribed specifically for alcohol dependence or abuse varies dramatically with the philosophy of various clinicians and treatment programs. In some hospitals, no patients are offered medications, whereas in others, no patient leaves without a prescription for a medication. Historically, 12-step programs have frowned on individuals receiving any psychotropic medication. In this more enlightened era, there is an increased understanding of psychiatric co-morbidities and this attitude has mostly disappeared.

What is Antabuse, and how does it work?

Antabuse is the first medication that the FDA approved for the treatment of alcoholism. It is in the class of medications that are used for behavior modification. As mentioned in Question 22 (Table 6), a correlation exists between those groups of individuals who are able to metabolize alcohol and the rate at which they are prone to alcoholism. The enzyme that metabolizes alcohol is aldehyde dehydrogenase. The groups of people who are more prone toward alcoholism have more aldehyde dehydrogenase available in their bodies to break down the alcohol, whereas people who are less prone toward alcoholism have less aldehyde dehydrogenase available. Thus, a decrease in aldehyde dehydrogenase leads to a reduction in the tendency toward alcoholism. Disulfiram (Antabuse) was developed to mimic this genetic variation by reducing the relative amount of aldehyde dehydrogenase. This medication inhibits or blocks aldehyde dehydrogenase, which reduces the amount of this enzyme in the body that is available to break down alcohol, thereby resulting in an accumulation of acetaldehyde when one drinks alcohol. Acetaldehyde causes nausea, low blood pressure, flushing, headache, and weakness. This can last anywhere from 30 to 60 minutes. The reaction varies with the amount of alcohol that is consumed. More severe reactions can include cardiovascular problems and convulsions. Other potential risks include peripheral nerve damage and hepatitis. One needs to wait at least 72 hours before his or her last drink before starting the medication because of the risk of having a bad reaction. Any food or medicine containing alcohol, including after-shave lotion, can potentially cause a reaction. Because of these risks, Antabuse is rarely, if ever, offered to people who are beginning treatment. A full medical history must be taken along with a battery of blood tests to rule out other medical conditions that preclude its use, such as liver or kidney disease, hypothyroidism, or diabetes. Patients rarely drink while taking this medication. Alcoholics who are motivated to maintain abstinence stay on the medication, and those who are not stop the medication and resume drinking. In other words, rarely does an Antabuse reaction ever occur to produce the negative consequences necessary to prevent continued drinking (see Table 10 for details).

Antabuse a drug given to alcoholics that produces nausea, vomiting, dizziness, flushing, and tachycardia (a fast heart rate) if alcohol is consumed; thus it is a deterrent to drinking and acts as a negative reinforcer.

Metronidazole Generic name for Flagyl, an antibiotic medication that rarely can have an Antabuse-like effect for patients taking It and drinking alcohol.

Table 10 Disulfiram Details

Drug Name

Disulfiram (Antabuse) — Decreases number of drinking days but does not increase abstinence. Directly observed therapy might be more beneficial but has not been studied in a good randomized trial.

Adult Dose

250 mg PO qd

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity, severe myocardial disease, coronary occlusion

Interactions

Do not administer with metronidazole; use with caution in patients on phenytoin (levels of phenytoin might increase)

Pregnancy

C — Safety for use during pregnancy has not been established.

Precautions

Adverse effects are uncommon, but hepatitis, optic neuritis, neuropathy, and skin rash reported

 
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