ALCOHOL AND ITS EFFECTS
We have established in previous articles some of the factors involved in alcoholism and drug addiction, an overview of the chronic disease model of addiction, and a need for significant change to maintain sobriety and recovery. This session will introduce one of the cutting-edge concepts used in the field of addiction care – Medication Assisted Treatment or MAT.
Using medication approaches to help prevent relapse on alcohol, help stabilize the brain, and to treat underlying pathology is nothing new. Dating back to the “Keeley Cure for Alcoholism,” which was offered between 1879 and 1965, clinicians wanted to use pharmacotherapy to treat this disease. Of note, the Keeley method for treating alcoholism was not successful. Keeley clinics involved hotel arrangements in which the alcoholic would drink excessively during the daily program and then take a cocktail of mild toxins to cause vomiting through the night. This pattern of receiving the desired substance and then connecting it to painful memories was thought to break the connection between alcohol and pleasure (i.e. Stanley Kubrick’s A Clockwork Orange). Although it was ineffective and did not produce long-lasting results, MAT was introduced as an option for therapy.
One of the core problems with the Keeley method was that it implied that alcoholism was ‘curable.’ There are even current treatment programs available in the United States which promote cures for addiction, and these programs are highly desirable by clients. Who wouldn’t want to be outright cured of a chronic health problem? A second problem of the Keeley method was the creation of an artificial environment which was not relatable to a person’s real life. Finally, for some alcoholics, the disease is strong enough that even treatments with harsh consequence do not carry enough weight to lead to lasting change. The person will actually trudge through the pain of the addiction to keep it going. That’s how strong the compulsion to drink really is for severe alcoholics.
Today there are three FDA approved medications for the treatment of alcoholism and multiple medications which are classified as ‘off-label.’ This category does not mean that they are ineffective, rather that they were somewhat ‘repurposed’ for the treatment of alcoholism. The necessary steps for FDA approval were never taken (this is typically financially driven: the off-label medications for alcoholism were all generic meds before they achieved good data for alcoholism treatment).
The three FDA approved medications include:
Examples of some of the off-label medications include:
There has been considerable debate within the 12-step community around the use of medications to assist the treatment of addiction. In some circles, any psychotropic medications (even Prozac) are not in accordance with principles of true recovery. People held an attachment to the spiritual and community power of Alcoholics Anonymous to such a degree that medications were thought to interfere with a potentially healthy recovery path.
Today, the central stance of Alcoholics Anonymous is that “We support what works.” Many sponsors through AA will comment to their sponsees that they are not doctors and hand over medical decisions to those with the appropriate training. Overall, the 12-step community has become more and more welcoming of MAT approaches, in part due to positive clinical studies and general safety of the medications.
The greatest resistors of MAT continue to be the prescribed people themselves. The concept of a medication to assist in recovery is often labeled as a ‘crutch’ and the person is reluctant to have something aiding their efforts. Ironically, the nature of using a crutch is ideologically part of a disease model for care – sometimes people need crutches while they are healing!
Resistance to a medication in early recovery raises questions about the legitimate motivation for change. Such medications as naltrexone are well-tolerated, have no abuse potential and can be used for periods of 3 to 6 months after a person has reached base sobriety. Because these months seem to be the most vulnerable to relapse, MAT is now the medical standard of care for alcoholism treatment towards the beginning of a change process.
There are some physicians who are resistant to prescribing these medications, although this may be a marker of discomfort with alcoholism itself. Because the expected value of a medication like naltrexone is high, a person should be offered a trial of it unless there are significant contraindications. If your physician resists using this medication as part of your treatment for vague reasons, it may be in your best interest to simply transfer to a new provider.
A scientific outline of the three phases of the disease model of addiction was defined by Nora Volkow, MD and George Koob, MD. Please read their article in the New England Journal of Medicine Jan 2016 for further details on this topic. These phases are as follows:
Any person who is struggling with an addiction will fall into one of these three phases at any given time. If we can identify the current phase, it is possible to use medications most applicable to a given phase to improve things.
Read more CeDAR Education Articles about Alcohol and Its Effects including Dual Diagnosis.