Motivational Interviewing: Helping People Change (3rd ed, by William R. Miller and Stephen Rollnick; Guilford Press, 2013) is an excellent resource for clinicians who wish to master this technique. An online tutorial in screening and brief intervention for alcohol or drug misuse is available free at https://adept.missouri.edu. Video demonstrations of motivational interviewing to address these issues are also available here ; to access them, click on “Training”, then on “Go to SBIRT videos”).
CASE Before Mr. F’s visit is concluded, you initiate a conversation about alcohol use, stating: “As your doctor, I’m concerned that the amount of alcohol you’re drinking could be hazardous to your health. I recommend that you cut down to no more than 4 drinks in any one day and to no more than 14 drinks a week.” You make it clear that change is up to him, and ask what he thinks about what you’ve said.
You also schedule a return visit in one month, at which time you will continue the conversation.
PHARMACOTHERAPY IS A USEFUL TOOL
Increasingly, alcohol and drug dependence—like other chronic conditions—can be effectively addressed with medication.
Drugs to treat alcohol dependence
Naltrexone. A daily dose of naltrexone, starting at 25 mg daily for a few days and going as high as 100 mg/d, can help patients with alcohol dependence limit their drinking to safe levels (number needed to treat [NNT]=9).29 This will reduce the risk of alcohol-related harm while the patient considers quitting.
The most common adverse effect is nausea, but a low starting dose may alleviate it. Naltrexone, also available as a 380-mg intramuscular (IM) depot injection once every 4 weeks, is an opioid antagonist and should not be given to any patient who’s taking opioids.
A 2010 Cochrane review found only 4 trials of naltrexone IM, and failed to show significant reductions in drinking.29 But post hoc analyses of trials of both oral and IM naltrexone found that those in which compliance was assured (either by direct observation or IM administration) had better outcomes than those in which it was not.30 Another post hoc analysis found that patients whose alcohol dependence was more severe derived greater benefits from the drug than those who were less severely affected.31
Acamprosate. Two 333-mg pills tid can help newly abstinent drinkers remain alcohol-free (NNT=9).32,33 The most common adverse effect is diarrhea, which may subside with continued use.
Combining acamprosate and naltrexone does not appear to be more effective than either drug alone. In a recently published meta-analysis comparing the 2 drugs, those taking acamprosate had slightly better rates of abstinence from alcohol, while naltrexone was slightly better in reducing heavy drinking.34
Disulfiram Unlike naltrexone and acamprosate, which work by altering the brain’s reward circuits, disulfiram blocks metabolism of ethanol, leading to the accumulation of a toxic metabolite and its punishing syndrome. The major problem with the drug is noncompliance, which can be addressed by enlisting the help of a caregiver or partner to ensure that it is taken daily. 35-37
Other medications that have been tested (though not approved by the US Food and Drug Administration [FDA]) as a treatment for alcohol dependence include:
- topiramate, which has been found to have modest efficacy in increasing the number of abstinent days and decreasing heavy-drinking days;38
- baclofen, which has shown efficacy in small clinical trials;39 and
- ondansetron, which has been shown to effectively treat early-onset alcohol dependence.40,41
For patients with depression and alcohol dependence, the combination of naltrexone and sertraline has been found to be superior to either drug by itself—and to have fewer adverse effects. 42 Gabapentin and lorazepam have been compared in treating alcohol withdrawal, with gabapentin resulting in greater efficacy and fewer adverse effects than lorazepam.43,44
Pharmacotherapy for drug abuse, dependence
For methamphetamine abuse and dependence. Two randomized clinical trials have studied medications for methamphetamine abuse and dependence. In one small study, topiramate did not increase the proportion of patients who achieved abstinence, but in a post hoc subgroup analysis, it did appear to help newly abstinent patients avoid relapse.45
In another study, mirtazapine significantly decreased the proportion of patients whose weekly urine tests were positive for methamphetamine (from 73% to 44%); no significant change was found among those on placebo.46
Both drugs were well tolerated, but compliance was low in both trials despite weekly counseling. Each has only one clinical trial to support its use, and neither has FDA approval for addiction treatment.
For marijuana dependence. In a study of 50 people seeking treatment for marijuana dependence, gabapentin 400 mg 3 times a day significantly improved the proportion reporting no cannabis use and whose urine tested negative for the drug.47