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Wednesday, April 1, 2015

Modern Medical Treatment of Alcoholism, By Dr. Bob Sterling - Guest Blogger



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Modern Medical Treatment 
of Alcoholism
By Dr. Bob Sterling - Guest Blogger



The classic treatment for alcoholism is AA.  There are some other organizations that claim to be strictly ecumenical and do not involve the concept of a higher power.  Organizations like Smart Recovery, are organized around well known principles that are used in addiction counseling called Cognitive Behavioral Therapy (CBT).  Smart Recovery and CBT try to get people to be very mindful of the concept of triggers, (environmental based cues that are paired with alcohol use.)  There is a strong associative memory area in the hypothalamus of the brain that reminds the brain to feel a craving around these paired cues, such as the smell of a bar and drinking. Or birthdays, weddings, holidays paired with the activity of drinking. Being mindful of these pairings can allow the individual to be prepared for the associative cravings that occur and to have alternative behaviors planned out in advance.  So if weddings trigger drinking, then at first, at least, one should avoid weddings.  If going to a ballgame is paired with beer drinking, that venue should be avoided.  If low lights and the tinkling of ice in a glass is a trigger, avoid being around such triggers.

Sometimes a smell might trigger a behavior, like hot dogs cooking on a grill.  Maybe a switch to cold cuts would be in order.

These treatments are always required even in the presence and use of medications known to curb the desire to drink.  So the following medications may be useful adjunctive treatments and I will illuminate their  uses. I will first list the medications and their basic affect on people and then explain the mechanism of how they work.

Naltrexone: an opiate receptor blocker that decreases the pleasure derived from a stimulus (alcohol, sex, eating all are pleasures that may be reduced to some degree).

Acamprosate: a medication that is supposed to reduce the phenomenon of craving. That is the condition of desire when people are exposed to situations, and stimuli that are paired cues to alcohol consumption.

Topiramate: it is an anticonvulsant medication that works to reduce the release of dopamine which is responsible for the pleasure felt when alcohol causes a high sensation.

Baclofen: is an antispasmodic medication used in uncontrollable muscle spasm found in neuro- muscular degenerative diseases such as multiple sclerosis and Lou Gehrig's disease. It appears to reduce the high and the craving in alcohol consumption.

Disulfuram (Antabuse): This works to interfere with the metabolism of alcohol.  It inhibits an enzyme in the metabolism of alcohol called aldehyde dehydrogenase.  This causes the accumulation of acetaldehyde in the blood and body and that triggers very uncomfortable noxious stimuli like rapid heartbeat, flushing of the skin particularly the face.  It raises blood pressure and causes intense anxiety. It's effect is often characterized like the sensation of dying from a heart attack. It is the activity of the acetaldehyde that causes the symptoms not the disulfuram itself.

Its main value is in avoidance of the alcohol so the combination will not trigger these uncomfortable sensations. It is a negative reinforcer.

The way these medications work is through a psychological mechanism described in the following explanation.  They all work to some extent but the real issue is that one has to take the medications.  If they are not taken, they don't work.

Naltrexone is the most useful of the medications for use in alcohol reduction and extinction.  50mg of Naltrexone daily is a very potent medication to reduce the desire to drink by making the drinks themselves less pleasurable. Naltrexone is an opiate receptor blocker. Opiate receptors respond to drugs like heroin and oxycodone and other narcotics which when used in excessive amounts give the person a "high".  Alcohol, similarly, stimulates the opiate receptors of the brain to trigger good feelings that are accompanied by drinking. When you block that receptor it cannot get stimulated and so pleasurable neurotransmitters (like dopamine) cannot be released.

You are familiar with the bell in Pavlov's dog experiment where the ringing of a bell is paired with food and the result is that the dog salivates before eating the food. If those pairings on done often enough, you condition the dog to expect food on hearing a bell ring.  The conditioned response is that  the bell rings and the dog salivates in expectation of receiving food. However, if you ring the bell often enough and do not deliver the food, the dog stops salivating.  This is call extinction behavior. That happens when behaviors (salivation), dependent upon paired stimuli (bell ringing) are no longer rewarded (food) and an extinction behavior develops (loss of salivation to the ringing of a bell).

In the case of naltrexone, it prevents the pleasure sensation when drinking, (the high).  So drinking causes a high (which is associated with environmental cues, such as the people with whom you drink). This pairing is manifested by anticipation of drink when accompanied by enough pairings. Soon, just being with the drinking buddies triggers cravings for alcohol.  If you reward that craving with actual alcohol then the conditioned reflex (craving) is reinforced so that eventually just the people trigger the craving without even the presence of the alcohol.

Naltrexone blocks that craving (or the high feeling that is caused by dopamine release in anticipation when exposed to the paired stimulus). So even if you do drink, you will not feel high. If you drink and don't feel high then eventually the association of drinking and high will be extinguished.  And after a long period of time, the associations of the drinking buddies with getting high will be extinguished too.

I hope this helps you in the understanding of the medical treatment of alcoholism.  You might ask how does AA work?  It works by first recognizing the triggers, (these paired stimuli) and by either avoidance or the act of NOT acting when exposed to these triggers (i.e. drinking) that behaviors are extinguished.  This, of course, takes a longer time than naltrexone but it might in some instances be more effective because behavior has been extinguished without the need for a medication so forgetting to take something is irrelevant to future behavior.

Bob Sterling 3/27/15

Dr. Bob Sterling, Westport, CT,  has been in medical practice for the past thirty five years.  During that time he has practiced Family Medicine, Ambulatory Care Medicine, Occupational Medicine and most recently Addiction Medicine. In all this time, what has become clear to him is the increasing prevalence of alcohol, marijuana and opiate addiction.  Also, an alarming trend is the increasing dependence and addiction to physician prescribed benzodiazepines.

Dr. Sterling currently treats patients with the above addictions bringing his unique perspective as a student of Alcoholics Anonymous. He uses this knowledge to support his treatment of all addictions; and as a student of AA practice and history, it provides the platform from which he moderates the regular meetings as a volunteer at Silver Hill Hospital, a substance abuse psychiatric hospital in New Canaan, CT. Dr. Sterling can be reached at sterlinb@optonline.net.

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