If alcoholism is a disease, is there hope of finding the cure in a pill?
Yes and no. Having mapped the physical changes the brain undergoes with years of habitual drinking, researchers in recent years have discovered a handful of promising — and some say underused — drugs that, combined with therapy, help alcoholics break the cycle of addiction.
To those for whom such remedies work, they certainly can feel like a cure.
“I felt like I had found something that finally helped me through the cravings,” said Patty Hendricks, 49, who used one such drug, naltrexone, to help control her drinking habit after four failed rehab attempts. “I don’t think I could have gotten sober without it.”
The problem is that alcoholics, like cancer patients, are not a homogeneous group. People drink compulsively for any number of reasons, from genetics to anxiety to post-traumatic stress disorder. The pill that helped Ms. Hendricks get sober might do nothing for, say, a veteran who drinks to ward off nightmares.
“Just as breast cancer isn’t just one type of breast cancer,” said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse, “alcoholism is heterogeneous as a disorder, so there’s clearly not one drug that is going to work for everybody.”
Instead, some addiction experts now envision a future — possibly no more than a decade away — in which treatment for alcoholism mirrors contemporary approaches to depression: Patients will choose from a range of drugs to find the one that best suits them, then couple it with therapy and other tools to achieve long-term recovery.
“What we hope to do is to actually have a menu of treatments that clinicians could choose from,” said Raye Z. Litten, associate director of the National Institute on Alcohol Abuse and Alcoholism. “If one drug doesn’t work or they can’t tolerate it,” patients would “try another one and so forth, and hopefully they’ll find one that is effective.”
Not everyone in the treatment community places stock on medication as a good path to sobriety. Both Alcoholics Anonymous and the Betty Ford Center, for example, have programs that emphasize abstinence, not pills or injections. Some critics say that treating alcoholism with medication amounts to simply substituting one drug for another.
It’s a far cry from the days when 12-step programs and self-control were considered the only paths to sobriety. But as doctors have come to view addiction less as a failure of will than as a chronic disease requiring long-term management, like diabetes or high blood pressure, the search has intensified for drugs that can help.
Of the medications currently available, only three have been approved by the Food and Drug Administration for treating alcoholism, and of those, only two — naltrexone and acamprosate — actually reduce the cravings to drink. (The third, disulfiram, sold as Antabuse, makes patients sick if they drink alcohol by blocking the body’s ability to metabolize it.)
By fine-tuning the brain’s chemical reward system, both acamprosate and naltrexone reduce the effects and the allure of alcohol for a subset of alcoholics. (The F.D.A. approved acamprosate, marketed as Campral by Forest Laboratories, in 2004. Naltrexone, now available as a generic, was first approved as an oral treatment for alcohol abuse in 1994 and, in 2006, became available as a monthly injection known as Vivitrol, made by Alkermes.)
Neither is a miracle drug. In dozens of clinical trials, both orally consumed naltrexone and acomprosate worked well for about one in seven alcoholics and had virtually no effect on the others. Dr. Litten said there were not enough real-world studies yet to determine how effective the drugs were in “naturalistic” settings, or how much overlap there was between the two groups who responded to each drug.
But the significance of these drugs far exceeds their efficacy, addiction experts say.
“When I went to medical school, if you suggested targeting alcoholism with a drug, people would say to you, ‘Young man, how could you ever hope to treat a chemical dependence with another chemical?’ ” said Dr. Markus Heilig, clinical director of the National Institute on Alcohol Abuse and Alcoholism. If nothing else, the discovery of these drugs “proves the truth that that notion is fundamentally flawed.”
More recently, scientists have found other drugs, some already approved by the F.D.A. for other purposes, that can help stop compulsive drinking. Dr. Bankole A. Johnson, chairman of the department of psychiatry and neurobehavioral sciences at the University of Virginia, conducted a study in 2007 that showed that topiramate, an antiseizure medication, not only reduced the urge to drink, but helped lower liver enzymes and blood pressure.
“It was just an idea that came into my head based on the basic chemistry of the compound,” Dr. Johnson said. Despite some unpleasant side effects (fatigue, confusion, nausea), topiramate has become a commonly prescribed off-label treatment for alcoholism.
Baclofen, an antispasm medication, is also sometimes prescribed off-label for alcoholics, though results of studies are mixed.
Dr. Johnson also showed that low doses of ondansetron, an antinausea medicine long prescribed to patients taking chemotherapy, could reduce drinking in alcoholics — particularly those with a specific genetic variant.
At the Scripps Research Institute in San Diego, George Koob is searching for drugs that address addiction from an entirely different angle: reducing the severity of the negative emotional states that drive former addicts back to using. One such drug, gabapentin, originally developed to treat epilepsy, has proved “very promising” in early studies, said Dr. Litten, of the National Institute on Alcohol Abuse and Alcoholism.
While some treatment centers have embraced the pharmacology, others say the emphasis on drugs can distract from the real work of rehabilitation.
“When you medicalize the disease and pay a lot of attention to the biology, it’s easy to get a patient to say, ‘Well, my cravings are gone, there’s nothing else I have to do,’ ” said Dr.Harry L. Haroutunian, physician director at the Betty Ford Center in Rancho Mirage, Calif. “We try to use the principles of the 12-step program as a source of strength during times of craving, to deal with the inevitable stressors. We want patients firmly involved with that.”
Dr. Haroutunian described the Betty Ford Center as an “abstinence-based program.” Patients who arrive already taking some kind of prescription drug for addiction won’t be asked to stop, he said, but others are unlikely to be prescribed such medication once admitted.
Conversely, the Hazelden Foundation, based in Minnesota, began prescribing drugs like naltrexone and acamprosate at several of its rehab clinics about six years ago. Today, 27 percent of the patients leave on some form of medication to curb cravings.
“We think it’s extremely important,” said Dr. Marvin D. Seppala, Hazelden’s chief medical officer. “In the first 12 to 18 months, people are highly likely to relapse. So anything we can do to keep people sober during that period really affects long-term outcome.”
Ms. Hendricks, who was a patient at Hazelden in 2008, said she might still be drinking if not for her two years on naltrexone.
“I think eventually I was strong enough mentally to know I could talk myself out of the cravings,” said Ms. Hendricks, who recently celebrated her 1,000th day of sobriety. “But you go through such withdrawal in the beginning, and naltrexone helped make the cravings shorter and less intense.”
Dr. Seppala said he tries to take patient history into account when prescribing drugs. He knows, for example, that naltrexone is supposed to work better in patients with a family history of alcoholism.
But real-world applications lack the clarity of a lab, he said. “The problem is that 95 percent of our patients have a family history. So it’s not a great predictor.”