Can Maintenance Medications Be Used In Abstinence Based Programs?
By Martin Peters, BA (Hons), Dip HE, RN
As practitioners, how often do clients ask the question: “is there a tablet that can stop me drinking?” Over the past 20 years pharmacology has become important in the field of addiction, but the evidence about the efficacy of medications that allegedly reduce cravings, or stop people drinking, are fairly erratic.
Big pharmaceutical companies continue to look for a magic drug that will ‘treat’ addiction, but realistically, even if such medications exist, compliance is also an important factor. While Disulfiram might have effective reactive properties that cause unpleasant sensations when alcohol is consumed, this does not necessarily reduce cravings. As a result, the drug has a poor rate of compliance and in essence, Disulfiram should not be seen as a long-term solution to enabling abstinence.
Saying this, there is absolutely no reason why Disulfiram shouldn’t be used as a support for clients who may initially be struggling with any form of abstinence, but have a degree of motivation and are receiving psychological interventions. It is imperative that any client who is prescribed Disulfiram is fully informed about its reaction to alcohol due to its slow absorption and elimination; in some cases, the effects may last up to two weeks after initial intake. Notably a case study by Fuler et al (1986) found that abstinence rates of patients on Disulfiram receiving a 250mg daily dose versus those that were receiving counseling only were insignificant. Interestingly, the reason for this finding was that only 20 percent were compliant with the medication regime. Nevertheless, in more controlled environments, along with ongoing therapy and compliance, abstinence is likely to be greatly increased. A study by Krampe H., Stawicki S., and Wagner T. et al. (January 2006) that followed 180 clients over a 7 year period found abstinence rates over 50 percent. Whilst Disulfiram was almost exclusively the medication of choice for alcohol dependency during the 20th century, new alternatives have come to the forefront in the last decade that potentially suggests a more pro-active way of promoting abstinence.
One such medication is Baclofen. Available since the mid-1950s, Baclofen is a derivative of gamma-amino-butyric acid (GABA). Historically used to treat spasticity, Baclofen is in the early stages of research for use in the treatment of alcoholism. A notable Italian study by Addolorato G., Leggio L., Ferrulli A., Cardone S., Vonghia L., Mirijello A., Abenavoli L. and D’Angelo C. et al. (Dec 2007) found Baclofen both reduces craving and alcohol withdrawal. The most well-known publication on Baclofen has been the writings of Dr. Oliver Amesien, a French Cardiologist who has battled with alcoholism for many years. In his memoir, “The End of My Addiction” (Farrar, Straus and Giroux, 2009), Dr. Amesien had sought help from various rehabilitation centers at least eight times and attended nearly 5,000 Alcoholics Anonymous (AA) meetings without being able to maintain sobriety. Dr. Amesien then began experimenting with Baclofen, and noticed that as he increased his daily dose his cravings were greatly reduced. Most interestingly, Dr. Amesien claims he has consistently been able to abstain from drinking altogether or drink moderately in social situations without having cravings or other addiction-related problems.
Despite this well-documented memoir, Baclofen as a frontline treatment is still in its infancy. A further study conducted in conjunction with the University of Glasgow found that, “Tailored Baclofen treatment in alcohol dependent patients with medical disease reduces self-reported alcohol consumption and results in significant improvement in craving and negative consequences of drinking. There may also be improvements in depression and anxiety, but quality of life appears unaffected. The overall satisfaction with tailored Baclofen treatment is high. Baclofen is a promising treatment option for alcohol dependency, which needs further study.” (Masson et al, 2011). Despite these promising findings, all studies to date have been relatively small in scale. To counter these concerns, a further study at the University of Amsterdam was commenced in 2011.
Whatever the findings of this new study, addiction therapists often discount the benefits of maintenance medications such as Baclofen as they are not compatible with a ‘total abstinence’ policy. Working steps and attending meetings is not always the solution for every client. Sometimes, we have to look at alternative ways of supporting people through their addiction by moving away from the ‘one size fits all’ treatment ideology. The big question is whether we sometimes do ourselves a disservice by maintaining that pharmacological interventions are not compatible with the principles of abstinence treatment? The short answer is perhaps. Efficacious treatment programs combined with maintenance medication may be extremely effective.
While the side effects of Baclofen appear to be relatively minimal, will a medication that is non-patented be championed by the medical profession and most importantly, large pharmaceutical companies? In an article in Time, Maia Szalaviz made a salient point, “At issue is the definition of treatment. In the U.S., successful treatment of addiction has traditionally been an all-or-nothing undertaking, involving complete abstinence – as promulgated by supporters of 12-step programs like AA – rather than a regimen of moderation. For many, that definition includes abstinence even from drugs that would help fight cravings. Indeed, for decades, experts have debated whether drug addicts who cannot or will not quit should even be offered ongoing treatments that would reduce harm related to their drug abuse. Although many providers have recently become more open to new options, the majority of American addiction treatment continues to use the 12-step abstinence model.” (Time, July 2009). While I am not advocating a harm reduction model of treatment within a primary rehabilitation setting, I feel we should be more open to supplementing our treatment modalities. Understandably, any pharmacological intervention should be followed up with addiction counseling and support meetings. Counselors should be open to innovative and hybrid approaches as opposed to the traditional ‘all or nothing’ philosophies. Why can’t some of the current medications be part of an abstinence based program?
Here in Thailand, there remains little knowledge of the use of such medications, other than in a harm reduction modality. In fact, Baclofen is not presently prescribed off-license. In the past 12 months, I have only worked with one client who was prescribed Baclofen with mixed results. As with previous maintenance medications, there are concerns about compliance. Maybe in the future Baclofen will come in the form of an implantable drug depot, but until further larger scale clinical studies are carried out this seems unlikely.
The emergence of Vivitrol in 2006 as a monthly injection offers some hope with regards to compliance issues. Saying this, how Vivitrol works in people with alcohol dependency is still relatively unknown and requires further long term research. Initial studies suggest that Vivitrol can manage alcohol cravings, but a significant part of treatment efficacy will again be in conjunction with counseling, although some researchers continue to doubt the compatibility of maintenance medications with an abstinence base. In a subset of patients who abstained from drinking in the week prior to receiving their first dose of medication, those treated with Vivitrol (380 mg) were more likely to maintain complete abstinence (without relapse) and showed a greater reduction in drinking days, as well as a greater reduction in heavy drinking days, compared to the placebo-treated group over a 6 month treatment period (James C. Garbutt, MD, Henry R. Kranzler, MD, Stephanie S. O’Malley, PhD, David R. Gastfriend, MD, Helen M. Pettinati, PhD, Bernard L. Silverman, MD, John W. Loewy, PhD and Elliot W. Ehrich, MD 2005).
Not surprisingly, a major factor that needs to be considered with any pharmacological intervention is the side effects associated with their use. Issues such as weight gain, dizziness, dry mouth, nausea and headaches will certainly affect compliance. If we can continue to keep an open mind as to what medications may be effective, and promote and support clients working towards abstinence, then in my mind, we should not automatically turn a blind eye to the benefits of maintenance medications.