Pharmacotherapy for Alcohol Dependence Clinical Addiction Research and Education Unit Section of General Internal Medicine Boston University Schools of Medicine and Public Health Supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) R25 AA013822
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Pharmacotherapy for Alcohol Dependence Clinical Addiction Research and Education Unit Section of General Internal Medicine Boston University Schools of.
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Pharmacotherapy for Alcohol DependencePharmacotherapy for Alcohol Dependence
Clinical Addiction Research and Education UnitSection of General Internal Medicine
Boston University Schools of Medicine and Public Health
Supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) R25 AA013822
Goal and ObjectivesGoal and Objectives
Objectives• To identify appropriate candidates• To describe and compare efficacy• To be able to prescribe pharmacotherapy and
monitor for desired and adverse effects• To be aware of the importance of providing or
referring patients for psychosocial therapy when using pharmacotherapy
• To describe pharmacotherapy options for alcohol use disorders in patients with comorbid psychiatric disorders
• To be aware of pharmacotherapies under study but not yet ready for routine clinical use
Goal: To understand the role of pharmacotherapy in the treatment of alcohol use disordersGoal: To understand the role of pharmacotherapy in the treatment of alcohol use disorders
Why Pharmacotherapy?Why Pharmacotherapy?
• Brain neurotransmitter physiology is abnormal• Effective alcohol treatments lead to
– 2/3rds reduction in alcohol problems– 50% reductions in consumption at one year
(with 1/3rd abstinent or drinking moderately)
• But treatment is far from completely effective• Even among people identified as having alcohol
dependence, only 10% receive treatment• Pharmacotherapy is beneficial when given in
addition to nonpharmacological therapies
• Psychological, medical, employment, legal, social services
• Removal from drinking environment• Mutual (self)-help groups• Counseling
• Motivational• Disease model (12 step)• Cognitive-behavioral• Marital and family therapy
Treatment for Alcohol Dependence:Treatment for Alcohol Dependence:Pharmacotherapy Plays a RolePharmacotherapy Plays a RoleTreatment for Alcohol Dependence:Treatment for Alcohol Dependence:Pharmacotherapy Plays a RolePharmacotherapy Plays a Role
Patient Selection for PharmacotherapyPatient Selection for Pharmacotherapy
• All people with alcohol dependence who are:– currently drinking– experiencing craving or at risk for return to drinking or
heavy drinking
• Considerations– Specific medication contraindications– Willingness to engage in psychosocial support/therapy– Relationship/willingness to follow-up with health
provider– Outpatient or inpatient clinical setting with prescriber,
access to monitoring (e.g. visits, liver enzymes)
Why is Pharmacotherapy NOT Reaching Patients?Why is Pharmacotherapy NOT Reaching Patients?
• Of patients treated for alcoholism, only 3 to 13 percent receive a prescription for naltrexone
• Alcohol dependence treatment system is not set up for long-term prescribing
• Lack of awareness• Evidence of modest efficacy, and lack of evidence of
effectiveness in practice• Side effects• Lack of time for patient management• Patient reluctance to take medications• Medication addiction concerns• Alcoholics Anonymous (AA) philosophy• Price/insurance coverage
Length of follow-up was as follows: Gerrein 1973: 8 weeks; Azrin 1976: 2 years, Azrin 1982: 6 months; Liebson 1978: 6 months. * Thirty-day abstinence at 6 months
Length of follow-up was as follows: Gerrein 1973: 8 weeks; Azrin 1976: 2 years, Azrin 1982: 6 months; Liebson 1978: 6 months. * Thirty-day abstinence at 6 months
Author, Yr Follow-up Disulfiram Abstinence
Gerrein, 1973 85%, 39%
MonitoredUnmonitored
40%
7%
Azrin, 1976 90% MonitoredUnmonitored
90-98%
55%
Azrin, 1982 100% MonitoredUnmonitored
73%*
47*
Liebson, 1978 78% MonitoredUnmonitored
98%
79%
PrescribingPrescribing
Helping Patients Who Drink Too MuchNIAAA, 2005
Helping Patients Who Drink Too MuchNIAAA, 2005
Prescribing DisulfiramPrescribing Disulfiram
• Main contraindications: recent alcohol use, pregnancy, rubber, nickel or cobalt allergy, cognitive impairment, risk of harm from disulfiram--ethanol reaction, drug interactions