Many people struggling with alcohol dependence who could benefit from medication are not receiving it, according to an expert who spoke at the recent American Psychiatric Association Annual Meeting.
“Antidepressant prescribing is 100 to 200 times as great as prescriptions for medications approved to treat alcohol dependence, despite the fact that the prevalence of disorders for which antidepressants are prescribed—major and minor depression and anxiety disorders—is only two to three times that of alcohol dependence,” says Henry Kranzler, MD, Professor of Psychiatry at the Treatment Research Center at the University of Pennsylvania and the Philadelphia VA Medical Center.
The reasons why medications to treat alcoholism are not more widely prescribed are complex. A main factor is that pharmaceutical companies and physicians have been afraid to deal with alcohol-dependent patients because they are concerned about the potential for out-of-control drinking to result in liability, for example, if a patient under treatment drives under the influence and has an accident, he says. Some doctors, as well as patients and their family members, also believe that alcoholism is not a suitable target for medication because, in their view, it only substitutes dependence on one substance for another.
Medication also may not be offered to many people with alcohol dependence because they are treated exclusively by non-medical personnel, such as counselors, Dr. Kranzler added.
Currently, three drugs are approved by the U.S. Food and Drug Administration to treat alcoholism: disulfiram (Antabuse), naltrexone (ReVia and Vivitrol) and acamprosate (Campral). “These drugs all exert modest effects,” notes Dr. Kranzler. Another drug that is prescribed off-label for alcoholism is topiramate (Topamax), which is approved to treat certain types of seizures and to prevent migraines. Topamax appears to correct a chemical imbalance in the brain caused by chronic drinking. Unlike treatments currently approved for alcoholism, it has been shown to be effective in people who are still drinking. However, it can cause side effects such as memory and thinking problems, as well as sedation.
Lundbeck, a Danish pharmaceutical company, has submitted an application for approval by the European Medicines Agency of the medication nalmefene to be used on an as-needed basis to reduce heavy drinking, according to Dr. Kranzler. “This is a novel approach and could have an impact on treatment throughout the European Union and possibly the U.S.,” he adds.
Last year, the company announced that nalmefene showed promising results in three clinical trials in Denmark. The drug can be used in patients who are still drinking.
“There are a number of companies in the United States and Europe that are developing novel compounds to treat alcohol dependence,” Dr. Kranzler says. “As we learn more about the neurobiology and genetics of alcohol dependence, it will be possible to identify novel mechanisms through which to intervene pharmacologically.”
This is an exciting time in the treatment of alcoholism, because the field of medication treatment for alcohol dependence is expanding into the arena of personalized medicine, he says. “There is growing interest in the use of a patient’s genetic variation to predict the response to specific medications,” he points out. “However, these findings are not yet ready for widespread clinical implementation. Additional research is required to allow them to be widely applied.”
Even with new medications, counseling should still be an important part of alcohol dependence treatment, Dr. Kranzler observes. “However, the personnel who are trained to provide counseling are not widely enough available to use this as the only model for treatment,” he adds. “There appears to be a role for medication combined with brief interventions that focus on promoting adherence to the medication and can be delivered in a primary care setting.”