Alcohol & Drug Anti-Addiction Medications
Anti-addiction medicines are important for the treatment of drug and alcohol addiction for many reasons. Since drug and alcohol addiction is a chronic disease that begins in the brain, Enterhealth Ranch and Enterhealth Outpatient Center of Excellence utilize anti-addiction medicines as a critical element of a comprehensive treatment plan personalized for each patient. Due to the powerful chemical changes that occur in the brain as the result of the injury from alcohol or drugs, cravings from deep inside the center of the brain drive each person to use, often overwhelming even the strongest logic and desire to quit.
Fortunately, amazing breakthroughs in drug and alcohol addiction treatment and medical scientific research have greatly facilitated long-term, successful sobriety by utilizing specific FDA-approved medications to shut down cravings in the brain.
The FDA approved Vivitrol in June 2006 for the treatment of alcohol dependence or alcoholism (as well as for the treatment of opiate, heroin and pain pill dependency in 2010). Vivitrol is an injection that is received in the glutteal (buttock) muscle once a month. During that month period, it slowly releases a medication called naltrexone into the bloodstream. Vivitrol (long-acting naltrexone) basically helps to prevent relapse to alcohol/opiate use by causing three things to occur.
- It decreases cravings for alcohol by up to 90%.
- If the patient does drink alcohol (or use opiates), Vivitrol blocks the euphoria or the “high;" therefore, when they are on Vivitrol, the patient can’t get drunk or high. When they do drink alcohol, they still have symptoms of intoxication, like driving or walking poorly; however, they do not benefit from any of the positive (pleasant) effects of alcohol. Consequently, because it is very frustrating to continue drinking when on Vivitrol, they are more likely to stop. Of course, your loved one, along with most alcoholics, are going to test whether they can get high (drunk) on alcohol or not. When they find out they can’t, they will say, “OK, the doctor was right. I’ll go listen to my counselor. There's no use testing it anymore, so now I’m just going to go learn how I can stay sober."
- Vivitrol prevents the first drink from “priming the pump” for more alcohol, and unlike alcohol use without Vivitrol, in which someone will have one beer which then seems to set off a “cascading compulsion” to have five or ten more beers in that sitting, the Vivitrol blocks that “priming” effect and the patient may only have half of a beer in total. By only having half of a beer, which does not even cause a buzz (based on the effect of the paragraph above), they are able to maintain appropriate judgment and stop drinking, leave the situation and call a therapist or sponsor to ask for help. This “new” healthy behavior severely limits the “severity of relapse” after the attempted sobriety and frequently allows patients to keep the relapse to a “slip” rather than it causing a full-blown relapse.
A common analogy to this situation (described in the third bullet above) would be if the patient is on a diet for weight loss. They may do “really well” on the diet for two weeks, and then on a Saturday evening, they go for that pint of ice cream in the freezer believing they will only have one spoonful, then end up having the entire pint. Once the diet is "broken," they give themselves permission to binge on other high caloric foods. Either an hour later or, for certain, the next morning, they truly regret breaking their diet and wish they would have been able to have a similar agent to Vivitrol that would curb their appetite and not let them enjoy the ice cream if they did eat it.
It is important to understand that although Vivitrol was only approved for use for alcoholism in the summer of 2006, the medication within the injection—naltrexone—has been approved for use in treating alcoholism since 1994. However, the problem with taking naltrexone orally (by mouth) is that patients with any chronic illness, who have to take medications on a daily basis, many times forget or stop taking the medication for a variety of reasons. Alcoholism is a chronic medical illness and alcoholics are not immune to the same “difficulty” issues consistently experienced by anyone with other chronic medical illnesses (i.e. diabetes) in taking these medications on a daily basis.
Ensuring that the oral naltrexone is taken on a daily basis requires high levels of clinician and family diligence to ensure doses are not skipped, or that the patient does not stop taking the anti-addiction medication altogether. They might find that taking the oral naltrexone works so well in stopping them from drinking alcohol, they might “clandestinely” stop taking the oral medication without telling their addiction support system or physician. Consequently, they have a much higher chance of relapse without the oral naltrexone.
On the other hand, with Vivitrol, you and your family members only need to remember to have you go to your physician’s office once a month to receive the Vivitrol. After that, no one has to worry about you adhering to the medication compliance program component of your alcohol addiction treatment for the next 30 days.
An addiction patient's response to Vivitrol can usually be seen within the first 2-3 days of starting the first injection. Consequently, Vivitrol works very quickly and has very few side effects. The primary side effect is nausea that occurs, if at all, in the first 2-4 days during the first injection period. After that time period any nausea is not usually an issue.
Patients on Vivitrol are overwhelmingly positive about its anti-addiction effects. In theory, those suffering from alcohol addiction should not be actively drinking when they receive the initial injection of Vivitrol. Vivitrol should be used as part of a comprehensive alcohol addiction treatment program. It is very important that the family members and physician strongly encourage the patient to participate in a comprehensive, intensive treatment program while they are taking Vivitrol or other appropriate medications as part of their addiction treatment.
Many patients will have the thoughts that “Doctor, you are giving me a shot; therefore, I don’t need to go to these other alcohol addiction treatments. Going to the treatment programs and trying to change my lifestyle is too difficult, and I would rather just take the easy solution and merely have to take the Vivitrol injection once a month or the injection plus other anti-addiction medication.”
Because these types of thoughts are common for all alcoholics, it is very important that family members and the physician/therapist strongly encourage and continuously check up on the patient's progress and attendance with the additional addiction treatment compounds. As noted above, these additional treatment compounds teach them the appropriate coping skills to allow them to learn to live in their normal environment, while dealing with the stresses with healthy coping skills rather that using alcohol or drugs as their primary coping skill.
Other Relevant Safety Information for Vivitrol/Naltrexone
Another benefit to Vivitrol is that it has very few side effects. Specifically, as I mentioned above, the primary side effects are nausea (which only occurs sometimes, but if it does occur, usually only occurs during the first 2-3 days of the first injection), occasional headache, some tenderness at the injection site for a short time afterwards, and some sedation. All of these symptoms are mild in most cases and much less toxic or evident than are the side effects alcoholism. Consequently, Vivitrol is very safe, well tolerated (meaning it has few side effects), and is not addicting.
One of the reasons that Vivitrol has few side effects is the unique way that it gets into the blood stream. By being injected into the muscle and then by being released into the bloodstream from the muscle, the naltrexone medication initially avoids going through the liver before it goes into the rest of the body. One of the liver’s main functions is to break down different substances (including medications). When any medication is able to bypass the liver initially, less of it is destroyed, so more of it is available to be used by various parts of the body. Therefore, theoretically, a patient needs a much lower dose to be effective.
Fortunately this is the case with Vivitrol. Remember that Vivitrol is just a time-released naltrexone. If naltrexone is taken by mouth (orally), it's necessary to take 50 mg/day X 30 days (length that Vivitrol lasts in your body) = 1500 mg of oral naltrexone for 1 month. At 50 mg/day oral naltrexone is safe, well tolerated, and has the same types of side effects as described above for Vivitrol. Because Vivitrol bypasses the liver, only 380 mg/month of Vivitrol is needed to treat alcoholism. Consequently, the fact that almost a 70% smaller dose of naltrexone is needed through the use of Vivitrol in your body each month may account for the minimal side effects experienced by most patients on it. Also, as an added bonus, because of the way that Vivitrol gets into the bloodstream, not only does it require less than 25% of the oral dose, but it also provides four times the brain levels of the oral dose, so more medication is available to help the brain.
In addition to the nausea issue mentioned above, there is what the FDA calls a “black box warning” on the labeling on the package insert for both Vivitrol and Naltrexone. This black box warning merely suggests that one might get significant liver-related problems if Vivitrol or Naltrexone is used for a long period of time without appropriate monitoring of the liver’s functions with blood tests. In fact, the black box warning for Vivitrol specifically states that there is no evidence of toxicity with Vivitrol.
Here is an explanation why there is a safety issue with naltrexone, which has nothing to do with Vivitrol or naltrexone in alcoholics. At one point, there was a study done on obese people wieghing over 300 pounds who already had a large “fat load” hitting the liver, so the liver was already slightly damaged. They were given oral naltrexone to see if it could help them lose weight by affecting the feeding center in the brain, thereby decreasing their food intake.
However, in this study the patients did not receive 50 mg per dose of naltrexone, which is the normal oral dose for alcoholics. Instead, they received six times the normal dose of Naltrexone or 300 mg per dose each day.
So, with six times the normal oral naltrexone dose given to these overtly obese patients, some of them developed elevated liver tests, yet, nobody died. They just had elevated liver tests. Consequently, because of the study, it is important to check baseline liver tests prior to starting Vivitrol or oral naltrexone and then continue to monitor it by getting a simple screening liver blood test three to four times a year. It is important to remember that naltrexone is a very safe medication, and it is infinitely less toxic to your body than is continuing the alcoholism. Alcohol is severely toxic to one's liver and the rest of the body. Consequently, the use of Vivitrol will help an alcoholic to stay healthy in the long run, as it effectively prevents him or her from using alcohol.
How Does Vivitrol Work?
Addiction researchers hypothesize that Vivitrol (naltrexone) works by blocking the interaction or the stimulation of the dopamine system (the body’s main rewarding system) by the alcohol molecule. When someone drinks alcohol, the alcohol molecules get into the blood stream through the stomach. The molecules, which are toxic the body's cells, travel throughout various organ systems, killing all kinds of cells as they go.
It is when these molecules reach the brain that they stimulate a variety of neuroreceptors with each different set of receptors basically causing different effects. Activation of some receptor systems cause the drinker to get sleepy (or sedated), yet others cause them to stop breathing resulting in death (alcohol overdose or poisoning). Vivitrol (naltrexone) is thought to block the link between the dopamine system (pleasure or reward system) and the internal endogenous endorphin/enkephalin (opioid) systems.
Luckily since we all have dozens of different types of neurotransmitter systems (brain chemicals) and these have a myriad of interactions with each other, even though Vivitrol can block the high/euphoria produced from alcohol (and opiates by the way, i.e., Vicodin/Oxycontin), one still can experience other good/positive feelings while taking this revolutionary anti-addiction medication. For example, when someone drinks alcohol, they can’t get a high, they can’t get drunk, but at the same time, if they get a good grade in school, if they get a bonus at work, or if they accomplish a full year of sobriety, they can still experience "good feelings." Consequently, when they are taking Vivitrol, their dopamine system is still functional and continues to help them feel good in a “normal” fashion.
Vivitrol is made up of molecules that are called microspheres, which are dissolved in a liquid and injected directly into one cheek of the buttocks (alternating sides each month). The actual Vivitrol microspheres, when dissolved in the injection solution, fill up like balloons and get “puffy." Picture these hydrated Vivitrol molecules as spherical chocolate chip cookies with big chocolate chips or chunks in them. Once injected, any little “chocolate chips” that are on the outside of the cookie that are in the body go right into the blood stream and one gets a nice healthy dose of naltrexone right away. And then over the month’s time that it is in the body, the entire spherical chocolate chip cookie breaks down or erodes and the “chips” on the inside come out and go into the blood stream in a very smooth fashion, so that one receives the appropriate dose of naltrexone evenly over the next thirty days.
The major scientific breakthrough of Vivitrol delivering this very effective medication for alcoholism for 30 days without stopping is a huge advance in your battling of this devastating, life-threatening disease. The fact that we now have a “shot” for alcoholism and opiate addiction will change many people’s view of alcoholism from that of merely a “sin, moral weakness or character flaw” to a major medical illness that is very treatable with a high degree of successful recovery.
Summary of Vivitrol’s benefits
Remember that the active ingredient in Vivitrol is naltrexone. The FDA approved oral naltrexone for treating alcoholism in 1994, and for treatment of opiate addiction in the 1970s. Consequently, it is already known to be safe and effective. Therefore, all of the benefits and effects of naltrexone on an alcoholic or opiate addict (decrease in craving by 90%, blocking the ability for alcohol to produce euphoria or a “high” so one cannot “get drunk”, and significant reduction in the amount of alcohol or opiates used, if drinking does start again) are seen with Vivitrol, as well.
However, when your family member is taking regular oral naltrexone, they must take it every day for it to be effective. If they do take oral naltrexone everyday, they have a very high chance of staying sober. But, because oral naltrexone is so effective, they could frequently have a “weak moment” and convince themself that they really are be able to drink normally again, so they will then stop taking the oral naltrexone (in many cases, they will pretend to everyone else that they are still taking it). Oral naltrexone’s positive “anti-alcohol” effects wear off after three days, so their cravings return and they can get “high” or drunk again.
Consequently, the breakthrough that is at the heart of Vivitrol’s success is that in addition to delivering all of the benefits of oral naltrexone, it also addresses the “critical” compliance issue in this disease in that you cannot stop it, even though you are having a “weak moment." For many alcoholics and opiate addicts, these weak moments will pass. And when they do, the addicts on Vivitrol in the Enterhealth program are very appreciative of the fact that they are still sober and still on a medication that will help keep them that way.
Vivitrol’s Positive Impact and the Family of an Alcoholic
Another critical success factor for the use of Vivitrol for the treatment of alcoholism and opiate addiction is that the patient's family or support system can significantly influence use. Because of the compliance benefit mentioned above, this ability of the family members/support system to be able to encourage patients to get to their Vivitrol injection appointment each month is huge in relapse prevention.
Once Vivitrol has been prescribed and your loved one has received the injection, your family now knows that, for the next 30 days they will not be able to feel “intoxicated,” “drunk” or “high.” In other words, they will not be able to experience any euphoria or positive benefit from alcohol or opiate use. Additionally, cravings will decrease by 90%, in general, and if they do take a drink, they will have much less compulsion to have more.
In the extensive research and clinical use of Vivitrol in addiction treatment practices, physicians have found that once a family understands these significant benefits of Vivitrol, in addition to the enhanced compliance issue, that they begin to feel some “control” returning to their very chaotic, “out-of-control” home environments they experienced in living with or interacting with an active alcoholic. Vivitrol is the first anti-addiction medication for alcoholism and opiate addiction that provides this sense of “control” for the family members, as the patient cannot change the effects of the medication once they receive the injection.
As soon as your family begins to feel this reassurance (control), the family members/support system of your loved one begins to realize just how much fear and uncertainty you have been living with in the past—how much you all worried if the patient was really taking the anti-addiction medication as directed or even at all, when would they relapse next, or when would “the chaos” return? Consequently, the use of Vivitrol can lift a huge burden of “worrying” and concern from the family members/support system’s shoulders. Not surprisingly, the alcoholic's family members/support system teams have become a tremendously strong and determined ally of the addiction specialist/physician in helping to ensure that the patient makes the follow-up Vivitrol injection appointments. The family members of Enterhealth patients and research subjects quickly realize that if they help the alcoholic or opiate addict to just get to treatment every 30 days, Vivitrol can make a tremendous difference in all of their lives.
Suboxone is the first opioid (narcotic) medication approved for the treatment of opioid dependence in an office-based setting. Suboxone also can be dispensed for “at home” use, just as any other medicine for other medical conditions.
The primary active ingredient in Suboxone is buprenorphine. Initially developed to treat pain, buprenorphine was adapted for use in treating opioid dependence in cooperation with the National Institute of Drug Abuse (NIDA) and was approved by the FDA in October 2002.
Overview of Suboxone and its Benefits:
Buprenorphine is a partial opioid agonist, meaning its opioid effects partially mimic those produced by full opioid agonists, such as oxycodone or heroin, and partially mimic those produced by opioid antagonists, such as naltrexone. Two formulations were initially approved: Suboxone and Subutex. Recently, two more have been added under the brands Zubsolv and Bunavail.
The first, Suboxone, contains buprenorphine and naloxone, an opioid antagonist to discourage people from dissolving the tablet and injecting it. Consequently, most practitioners only prescribe Suboxone to their narcotic addicts, as it has even less potential for diversion (being sold on the street) or other misuse.
- Subutex is rarely prescribed in clinical practice, the discussion here will be limited to Suboxone, but most of the information prescribed here is relevant to Subutex as well.
Suboxone is used to reduce illegal opioid use and to help clients stay in treatment by blocking the effects of opioids, decreasing cravings, and suppressing any major symptoms of withdrawal. Most narcotic addicts seem to benefit from Suboxone regardless of their histories of opiate addiction.
Suboxone is very safe, effective and is a revolutionary step in the treatment of narcotic addiction. It can be easily used in both the withdrawal stabilization (detoxification) and maintenance phases of opiate addiction treatment. Also, because of its ease of use and excellent safety profile, its use by the growing number of primary care physicians who are screening for and recognizing narcotic addiction in their practice populations should make a very positive impact in the treatment success rates for narcotic addicts.
Suboxone has several advantages over other opiate addictions treatments both for withdrawal stabilization (detox) and its long-term maintenance uses. A great number of advantages to this anti-addiction medication are created because of its chemical structure.
With these receptor functions (full agonist, antagonist and partial agonist) in mind, one can understand that methadone, which is a full agonist, would bind to the opiate receptor and produce the full response that would help you reduce your cravings, but it also might give you a high. When Suboxone ( a partial agonist) binds to the receptor, it completely satisfies the receptor that there is an opiate there, but it doesn’t produce any high or euphoria. Consequently, it’s addictive potential is extremely low. Again, the receptor is activated with Suboxone, which significantly reduces the cravings for opiates, which then, in turn, significantly prevents the chances of a relapse, but it also acts as a receptor antagonist, so normal agonists are not able to elicit the normal response. So, if you are taking Suboxone and then you try to “shoot up” heroin to get a high, Suboxone blocks the heroin from causing a high because the heroin can’t get to a receptor. Consequently, you don’t get a high, which is a very disconcerting feeling for the opiate addict who has just spent a great deal of money on a addictive drug that gave him or her no effect.
Because of the chemistry involved at its brain the receptor, Suboxone has several inherent safety mechanisms:
First, it is very safe in an overdose situation, because of the way it interacts with the receptor. If you try to take too much of Suboxone, it actually becomes a full antagonist and “punishes you” by putting you into withdrawal. This is quite the opposite of most agonists, such as heroin or Lortab, where the more you take, the more “high” you get. Yet eventually, with these full agonists, not only do you get a high, you also shut down your breathing and you die inadvertently from not being able to breathe. However, because of this different chemical structure, if you do take an overdose of Suboxone, you will put yourself into withdrawal and your breathing will become extremely hyperactive rather than shut down, so you won’t die. You will be very uncomfortable, but you won’t die.
Additionally, because of the way Suboxone interacts with the receptor—the medication has a very long duration of interaction— meaning you can easily take it once a day or sometimes every other day and still achieve a certain “normal” feeling, an effective dose, where you do not have cravings for your drug. Also, if you forget a dose on a particular day, you will not go into a full opiate withdrawal, so you can wait until the next day when you can get your medication.
- Because Suboxone binds so tightly to the receptor, as mentioned above, if you try to “shoot up” a narcotic or take narcotics to get a “high” during a “weak” moment, you won’t feel any of those effects and consequently, you will be less likely to have a relapse in the future when your are on Suboxone.
Finally, not only is buprenorphine safe, inherently on its own, the medication Suboxone is actually a combination of buprenorphine and naloxone. Naloxone is an opiate antagonist like naltrexone, but it is a very short-acting one that only works if you inject it intravenously in your veins. Consequently, the naloxone, when taken by mouth with the buprenorphine in the Suboxone tablet, does not cause any withdrawal symptoms or even cause any uncomfortable feelings for the client.
So not only is this combination medication a deterrent for the people on the anti-addiction medication, it is also a deterrent for people trying to steal the medication and use it on the street. Because the naloxone is part of the Suboxone tablet, the street value of Suboxone is very low; consequently, it is much less likely to be stolen from you. This is not the case with methadone or other standard agonist narcotics, such as Lortab or Oxycontin.
The combination of these four main attributes of Suboxone, plus many others, makes it an ideal and even a revolutionary, anti-addiction medication, which has come to the aid of clients with opiate addiction.
Guidelines for the use of Suboxone in Opiate Addiction
In regards to Suboxone dosing, it is very important that Suboxone is started for the first time, when the opiate addict is in withdrawal or is in detoxification. If you try to start an opiate addict on Suboxone while he or she is still comfortable, because they have opiate in their system and are not in withdrawal, the Suboxone will act like an antagonist and will put them into chemical withdrawal immediately. However, if you ask the opiate addict to wait for several hours or for the appropriate time period until the withdrawal begins, once they are in mild to moderate withdrawal, when they begin Suboxone, it acts as an agonist at the receptors and they calm down and feel much more comfortable.
Usually the first 2-3 days of being on Suboxone and adjusting it to the proper dose for that particular client is the “rockiest time” for clients. Once the client is on a stable dose of Suboxone, they are very comfortable, they have no cravings, they have no desire to use, and they actually feel quire “normal”. It is a very positive feeling for the patient to feel “normal” and not feel desire for narcotics. These feelings allow the addicted client to participate very positively in a residential or an outpatient addiction treatment program and/or 12-step program. This way they can finally learn the coping skills that they need to maintain a sober lifestyle going forward.
Once the opiate addicted patient stabilizes on Suboxone (usually within 5-7 days of starting it), it is up to the client and the physician as to how long the patient needs to be on the Suboxone. It is generally accepted that most addicts will need to be on it for approximately 9 months to 1 year, as a starting point, in order to allow their system to get stabilized, and then taper off slowly while they continue other aspects of their addiction treatment program.
Once you are off Suboxone, being on Vivitrol for at least another year to two years is a further deterrent to relapse. Consequently, once the recovering addict has tapered off of Suboxone under the direction of their physician for approximately two weeks, all patients should then get on Vivitrol (time-released naltrexone). Prior to the advent of Vivitrol, oral naltrexone was frequently prescribed for clients when they stopped methadone or other narcotics, because once they are taking naltrexone, if they try to use an opiate, they won’t feel any high or euphoria. Consequently, with Vivitrol, there is a much less likely chance that they will try an opiate during a “weak” moment in their addiction recovery process, say during a time of high stress, because they know that the opiate will not help them deal with the particular stress, if it does not provide any high/euphoria or relaxation response.
However, in addition to Vivitrol, oral naltrexone has also been successfully used to treat narcotic addiction. Once-daily ingestion of a 50 mg tablet will almost completely block any narcotic at the receptor site that a narcotic addict will attempt to use. Consequently, naltrexone prevents any euphoria or other benefit that an addict may hope to achieve through a relapse. Because daily administration is required, it is best to have an addict take naltrexone under direct observation to enhance their compliance. There is strong data that Vivitrol significantly enhances a sobriety program when used with impaired professionals who are motivated to stay sober (physicians).
Either way, whether oral naltrexone or Vivitrol is used with an opiate addicted client, they need to continue to stay engaged with the rest of their comprehensive addiction treatment program. Remember, anti-addiction medications are only 1 component of this comprehensive plan.
Campral (generic name: Acamprosate), a medication that has been widely used in Europe since the late 1980s to reduce alcohol cravings in alcoholics who have quit, was approved by the U.S. Food and Drug Administration in 2004 to treat alcohol dependence in the United States.
Although the precise mechanism of action or “cellular target” of Campral is unknown, it appears to decrease cravings primarily by restoring the balance in certain neurotransmitter pathways (most likely GABA + Glutamate) that have become altered by chronic alcohol abuse.
The GABA neurotransmitter system in the brain is a very important control system that is responsible for “calming you down” and helping you to relax. Because it calms you down, it is referred to as an “inhibitory” system. The Glutamate neurotransmitter system in the brain is just as important as the GABA system, but it has the opposite effect on the body: it causes you to get energized (referred to as your “excitatory” system).
Another way to look at these two important systems is to take an analogy of a car. The GABA system is like your brakes, allowing you to slow down, while the Glutamate system acts like the accelerator. If you have a car with only one system or the other, it is not a very functional car—you need both systems to balance each other out in order to be able to use the car effectively.
So, when anyone drinks alcohol (not just an alcoholic, but anyone), it stimulates the GABA system in your brain and you become sedated and relax. (The brakes slow you down). At the same time the Glutamate system is suppressed (so the accelerator is not being pressed). When the alcohol wears off, your excitatory system “rebounds” and you feel more irritable, agitated, and may find it difficult to sleep (remember: the brakes are now off and the accelerator is being pushed).
Now, if you are an alcoholic, you have been drinking regularly in most cases and you develop tolerance-meaning you require more alcohol to achieve the same effect. What tolerance basically does to the GABA/Glutamate systems is that it modifies both in some respect; but at the end of the day, an alcoholic must consume more alcohol to "put on the brakes" (slow down and relax). Then when the alcohol wears off, the Glutamate system has become somewhat “turbocharged” and the result is that the accelerator seems to be “pressed to the floor” resulting in quite severe withdrawal symptoms in many cases.
Alcohol Withdrawal Symptoms
If you think about it, alcohol withdrawal symptoms are the result of many body systems being stimulated, blood pressure and heart rate are increased, you are irritable, and it is difficult to calm down or go to sleep. Even after the first 5-6 days of alcohol withdrawal have passed and the more severe withdrawal symptoms have gone away, the Glutamate system still seems to be “overly active” and the GABA system still seems to under perform. The result is the “post-acute” alcohol withdrawal phase; when the alcoholic remains irritable at times, has persistent insomnia, has difficulty concentrating: all symptoms of a hyperactive accelerator and somewhat weak brakes.
Thankfully, in the “post-acute” alcohol withdrawal phase, these symptoms are only intermittent. Recovering alcoholics feel fine at times, but during periods of stress, they seem to get “extra hyper”. It is during these “extra hyper” times that they experience some combination of these symptoms, which then can produce alcohol cravings, which then can increase the chance of a slip or even a full relapse.
What Campral appears to do is, after a 4-6 week period of taking it on a daily basis, it seems to restore the normal balance of the GABA/Glutamate interaction. (In other words, it seems to begin to restore the brake system and accelerator back to their normal functioning levels). Consequently, alcohol addiction patients on Campral report that after the first 4-6 weeks of being on it, they begin to feel calmer, can handle stress more effectively, can concentrate and focus better, as well as having decreased cravings or desire for alcohol.
Unfortunately, these significant improvements for an alcoholic take at least a month to begin to appear. Sometimes it is very hard for an alcoholic to wait that long, because they are so used to “instant gratification”, that they get impatient and stop the anti-addiction medication prematurely. Also, when the positive effects appear, they usually develop slowly over 2-4 weeks and so there is no overt, pronounced effect. But one day, 6-10 weeks after starting the Campral, alcoholic’s report that they notice that they are just “a lot better”, are more relaxed, are sleeping better, and have significantly reduced alcoholic cravings.
Once you are convinced to take Campral with the above facts and reasoning in combination with a medical evaluation by an addiction specialist, the next challenge with Campral is actually taking the medication. Unfortunately, Campral is not well absorbed by your gastro-intestinal tract. In fact, only 10% of each pill is absorbed. So, in order to get the 200mg/day of Campral into your blood stream that you need to begin to heal your GABA/Glutamate systems, you need to take six tablets per day (1998 mg) in order for the medication to work. Addiction patients usually take it 2 tablets three times a day, but it is difficult for anyone to take any medication three times a day without forgetting that middle of the day dose. Therefore, I usually prescribe two tablets three times a day for the first two weeks and then have my Campral patients change to taking 3 tablets twice a day thereafter, so that they do not have to take the lunch time (or midday doses).
A related issue that comes up for some addiction patients is that they say, “Doctor, I don’t want to take six tablets each day. That is too much medication. I don’t want to put anything in my body that will hurt me or I don’t want to get addicted to Campral.” Obviously, these arguments are ludicrous as this anti-addiction medication will give them a great chance to stop using alcohol—an addiction to a very toxic substance that is already killing them. Also, Campral is not toxic at all to the body and, like Vivitrol or naltrexone, it is not addicting or abusable. Also, once most patients understand about the poor absorption of Campral being the reason that they have to take 6 pills a day, they usually do not mind taking that many pills a day.
Finally, some alcoholics are resistant to taking medication to help them because they are not truly committed to stopping alcohol. Regardless, they could be strongly encouraged (and required, if possible) to take the medications and then encouraged to work through their ambivalent feelings about starting in a treatment program and/or attending AA meetings, while the medication is starting to help them feel better. Remember, Campral, just like any other addiction medications, need to be taken as one part of a comprehensive addiction treatment plan.
Fortunately, the side effects of Campral, like Vivitrol, are minimal. The main one is diarrhea and this is quite infrequent, especially after the first 1-3 days of taking it. If diarrhea does occur, over-the-counter medications, such as Imodium, are very effective. Other even less common side effects are nausea, itching, and intestinal gas. Also, Campral, like Vivitrol, does not interact with other medications, so it can be added to just about any current medication regimen without concern, as long as your doctor is aware of all of your medical conditions and other medication that you are taking.
Most patients stay on Campral for at least a year and a half and then, depending on how they are doing in their recovery program, they and their physician can consider and discuss discontinuing it.
From a scientific standpoint, fourteen out of 16 controlled clinical trials in European countries have demonstrated evidence for its effectiveness, showing that acamprosate-treated patients have a significantly greater rate of treatment completion, time to first drink, and abstinence rates than patients treated with placebo.
Disulfiram (Antabuse®), a sensitizing or deterrent agent, was approved by the FDA for the treatment of alcoholism in 1951. It has been used as an aid in managing chronic alcoholic patients who want to remain in a state of enforced sobriety, so that they can participate in residential, outpatient treatment and 12-step programs effectively.
Disulfiram produces sensitivity to alcohol that results in a highly unpleasant reaction when the patient taking it drinks even small amounts. It does this by interfering in the alcohol enzymatic metabolism (breakdown) pathway resulting in an accumulation of a chemical (acetaldehyde) in the blood. This toxic by-product of normal alcohol metabolism produces a complex of highly unpleasant symptoms, including intense nausea and vomiting, sweating, flushed skin, throbbing headache, respiratory difficulties, blurred vision, and confusion.
Antabuse has a valid place as an integral part of certain recovery programs. However, because of its toxic reactions, it does have some safety issues, although they are much less concerning than the safety issues related to continued alcohol use. Because of these safety issues, it is not usually used as a first line treatment for alcoholism any more. Rather, it is a medication to be used only if all other standard treatments fail, or it can be added to other pharmacological strategies, such as adding it to Vivitrol/Campral or Campral by itself.
When Antabuse is used, it is very important that it is given to you under a monitoring situation. You need to be watched while you are taking it each morning, and your mouth should be orally inspected after swallowing each tablet, in order to ensure compliance. If the compliance is ensured via a visual monitoring (observation) program, Antabuse can be very effective when used as a component of a comprehensive addiction treatment program.
Unlike Campral, however, Antabuse acts only as a deterrent; it does not heal any of the damage caused by the alcoholism. The usual dose of Antabuse is 250 mg/day and liver function blood tests should be obtained by your primary care physician on a quarterly basis (4 times/year).
One of the complications of taking Antabuse is that it can cause the typical toxic reaction even with very small amounts of alcohol, even if they are taken accidentally. Consequently, when you are on Antabuse you have to be very careful to not use certain alcohol containing products (perfume, mouth wash) very carefully. Also, certain sauces for food can contain small amounts of alcohol and cause a reaction. However, if you are carefully observant of your environment, these hazards can be easily avoided.