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May 1, 2000
Conquering the Craving
Pharmacotherapies treat alcohol addiction
By Leah Shafer

illustration: Barbara Shone

Maureen C. knew she had a drinking problem when she began blacking out during time she spent with her children. She couldn't remember driving them around or watching television together. Her alcohol use was rapidly escalating, and her life began spinning out of control.

Knowing she needed help, Maureen turned to Alcoholics Anonymous (AA). But sobriety proved elusive. "AA didn't work for me," she said. She felt depressed and alone, with a heightened desire to drink after meetings. "I thought, maybe this is not the right thing for me."

She turned to a hospital outpatient program near her Indiana home, where her psychiatrist suggested she take disulfiram (trade name Antabuse) during recovery. Disulfiram was one of the first medications developed to treat alcoholism some 50 years ago. The drug creates a heightened sensitivity to alcohol in the patient, so that any consumption of alcohol results in some very disagreeable reactions: sweating, nausea, and profuse vomiting for starters. Maureen was already getting sick every day from drinking and reasoned if that wasn't stopping her, disulfiram wouldn't either, so she refused to take it.

When she started reading about naltrexone, a new drug with promising results in treating alcoholics, she felt a surge of hope. Maureen lugged a binder full of information to her family doctor and asked for a prescription. He was not familiar with the drug and was resistant to her request. After a month of persistent badgering, Maureen got her prescription.

As Maureen took the naltrexone and underwent psychotherapy, she changed her view of alcoholism; instead of thinking of it as a life sentence, she began to think of it as a medical disease she was fighting to cure.

sidebar: Short History of Drug Development

Curing the craving

Overcoming the enormous hurdle of alcohol addiction usually means a period of white-knuckled craving during which the goal is simple, though not easy: to make it moment-to-moment without a drink. Of the one million Americans treated each year for alcoholism, almost 50 percent start drinking again in the first few months of sobriety. But naltrexone, among a class of medications called opiate antagonists, appears to offer hope to alcoholics and has garnered the attention of the medical community. When compared with a placebo in clinical trials, naltrexone consistently reduced the rate of relapse to heavy drinking as well as the frequency of drinking. Opiate antagonists have been used for more than 20 years to help people kick addictions to drugs such as heroin and morphine. Researchers express excitement about the potential of these medications to treat alcohol addiction as well.

One of the primary investigators of naltrexone treatment for alcohol dependence is Joseph Volpicelli, M.D., Ph.D., associate professor of psychiatry at the University of Pennsylvania. He explains that one of the reasons humans like to drink is for the endorphin "high" that alcohol causes. "When you drink, your brain releases these morphine-like compounds called endorphins," he says. "These ... create the need to have another drink and cause the pleasurable effects of drinking."

Opiate antagonists, such as naltrexone, bind to the endorphin receptors in the brain -- the same parts that are stimulated by endorphins -- but do not activate them, Dr. Volpicelli explains. As a result, cravings are reduced, and if the alcoholic drinks, the sense of "high" is greatly reduced -- in some patients, by half.

"When an alcoholic is taking naltrexone, if he doesn't drink, he doesn't feel anything," says Dr. Volpicelli. "But if he does drink, it tastes different in a way he can't describe; it just doesn't hit the spot anymore. He will start sipping the drink and will do something he has never done before: leave the drink on the bar half-empty."

By treating the symptoms of alcohol withdrawal, naltrexone gives patients a better chance of staying sober, said Alex Stalcup, M.D., medical director at the New Leaf Treatment Center, in Concord, California. "Management of craving is a new approach to the treatment of addiction, and naltrexone is the best example we have of an anti-craving medication," says Dr. Stalcup.

Notably, the idea treating the symptoms of alcoholism goes against the grain of the Alcoholics Anonymous fellowship. For the two million AA members worldwide, there is no such thing as a cure, but rather an ongoing, lifetime effort to stay sober and to help other alcoholics get sober. As a general rule, the use of naltrexone or other pharmacotherapy treatments is frowned upon in the 12-step AA ethos, which views alcoholism as a spiritual disease and thus requires the strength for sobriety to come from within the individual.

Clean and sober

As Maureen's craving to drink diminished during treatment, she began to work on some personal issues. "Alcohol was my crutch with my family," she explains. "When things got bad, I used to drink. This helped me face life better."

Naltrexone can have serious side effects; in high doses, it can cause liver damage. Because alcohol abuse can also cause liver damage, naltrexone is contraindicated in many of the people who might need it most. The severity of the drug's side effects, ranging from nausea to headaches, caused 15 percent of participants to drop out of the largest naltrexone study. Also, naltrexone can help alcoholics only with their craving to drink; it does nothing to address the emotions that led to drinking. Facing this sandbox of buried feelings sends many people hurtling toward relapse.

Maureen has fallen off the wagon a few times since she got sober, but managed each time to stop drinking again without a major incident. She credits naltrexone for that, supporting Dr. Stalcup's sentiments regarding the true benefit of opiate antagonists: their ability to keep a "slip" from turning into a binge gives alcoholics a little grace to get back on their feet without a full-blown relapse.

But even with these benefits, naltrexone is a relative unknown in treatment centers. There are fewer than ten centers in the United States that use the drug as part of an alcohol recovery program. But Dr. Stalcup says if alcoholics can't find a spiritual or rehabilitative treatment that works for them, a family doctor could prescribe naltrexone and monitor their use of it.

"Family practitioners can comfortably, safely, and wisely prescribe naltrexone," Dr. Stalcup says. "The side effects are very limited, and the impact is enormous." For Maureen, the results are lasting sobriety and a sense of having conquered her alcoholism. She's been clean since October 1999 and off naltrexone since February of this year. "It literally saved my life," she said. "It is very difficult to get off of alcohol, to relearn how to cope day after day. You have to relearn how to make other things important."

Related links:

Outside link: Alcoholics Anonymous

Outside link: National Institute on Alcohol Abuse and Alcoholism