ALCOHOL AND ITS EFFECTS
Most drugs of abuse act through relatively straight-forward mechanisms on the brain. Cocaine and methamphetamine directly trigger the dopamine system, which has vital importance for pleasure and reinforcing behaviors. Opioids painkillers and heroin act on the mu-opioid system in the brain, responsible for pain relief, sleep connections, and secondary dopamine transmission. Nicotine acts on the cotinine receptors in the brain.
Alcohol acts in more diffused and complex ways than these above drugs, putting pressure on multiple different neurological systems. One of these systems, the GABA/Glutamate pathway, was discussed in our last session. Another vital system important for us to utilize in addiction recovery treatment is the opioid painkiller system as it is connected to alcohol processing.
In 1982, the medication Naltrexone, a mu-opioid blocker, was approved by the Food and Drug Administration (FDA) for the treatment of opioid dependence. The rationale for this approach was based on pure behavioralism – if we could block the effects of heroin or other opioids on the brain, behaviors would essentially extinguish due to no attached reward to the drug use. Animal models over that time showed that mice, when administered naltrexone or a similar medication, naloxone, largely decreased alcohol consumption patterns. These accidental findings led to further research on the topic and eventually naltrexone was FDA approved for the treatment of alcoholism in 1994.
The initial mechanism of action for these findings was unclear. How was the opioid system in the brain connected to alcohol use. Although the full mechanism is not entirely understood, repeated research studies matched against placebos have shown naltrexone to be a Tier 1 medication in the treatment of alcoholism. The postulated mechanism, as originally cited in a 1997 paper, is as follows:
Naltrexone treatment targets the actual reward pathways involved in the disease of alcoholism. Multiple studies have demonstrated its efficacy in reducing cravings to drink alcohol, decreasing the number of heavy drinking days per month, and increasing the number of full abstinence days in per month.
In 2006, one of the larger studies (1,383 people) in the field of addiction was conducted through multiple sites in an attempt to analyze therapy options and medication options for the treatment of alcoholism. It reviewed people with alcoholism in outpatient settings to determine which medication approaches offered the greatest benefits as well as reviewed structured addiction-focused therapies as compared to standard medication-management approaches provided by primary care physicians.
There were multiple important findings from the COMBINE study which are highly useful as we work to design appropriate treatment plans for people.
Evidence from the COMBINE study can guide your decision to seek treatment. Advanced addiction counseling offered some benefit for people, but simple approaches with the use of Medication-Assisted Treatment (MAT) showed the best, most efficient outcomes. Our goals in presenting this information to you are that if you wanted the most ‘Bang for the Buck’ in terms of addiction recovery care, take note of the COMBINE study and use the science to improve your health!
 Spanagel R, Zieglgansberger W. (1997). Anti-craving compounds for ethanol: New pharmacological tools to study addictive processes Trends in Pharmacological Sciences 18 2 54-59. [Reference list]
 Anton RF, O’Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA. 2006;295(17):2003–17.