Naltrexone and acamprosate are categorized as anticraving drugs. Disulfiram is an aversion drug. Other types of medications, such as antidepressants, may also be used to treat patients with alcoholism.

Anticraving Medications

Anticraving drugs are opioid antagonists. These drugs reduce the intoxicating effects of alcohol and the urge to drink

Naltrexone. Naltrexone (ReVia, Vivitrol) is approved for the treatment of alcoholism and helps reduce alcohol dependence in the short term for people with low-to-moderate alcohol dependency. ReVia is a pill that is taken daily by mouth. In 2006, the FDA approved Vivitrol, a once-a-month injectable form of naltrexone.

Naltrexone is usually prescribed along with psychotherapy. The most common side effect is nausea, which is usually mild and temporary. High doses can cause liver damage. The drug should not be given to anyone who has used narcotics within 7 - 10 days. For ReVia, it is important that patients take the pill on a daily basis. Because many patients have difficulty sticking to this daily regimen, a monthly injection of Vivitrol may be an easier option.

Naltrexone does not work in all patients. A 2003 study suggested that people with a specific genetic variant called ASn40 respond better to the drug than those without the gene. The gene regulates receptors that affect the response to opioids. A 2005 study indicated that naltrexone works best for patients who have a family history of alcoholism, began drinking at an early age, and abuse other drugs.

Research is being conducted on the effects of combining naltrexone with acamprosate (Campral), particularly for individuals who have not responded to single drug treatment. In a 2006 study in the Journal of the American Medical Association that examined various outpatient drug and behavioral treatments, naltrexone worked as well as psychotherapy in preventing relapse to heavy drinking for patients who had recently abstained from alcohol. However, the study showed no benefit for acamprosate either when combined with naltrexone or used alone.

Acamprosate. Acamprosate (Campral) is the newest drug to be approved for treatment of alcoholism. Acamprosate calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). Studies indicate that it reduces the frequency of drinking and, in concert with psychotherapy, improves quality of life even in patients with severe alcohol dependence. One study reported that 60% of patients remained abstinent for 12 weeks, and in another 43% were still abstinent after nearly a year. The drug may cause occasional diarrhea and headache. It also can impair certain memory functions but does not alter short-term working memory or mood. People with kidney problems should use acamprosate cautiously. For some patients, combination therapy with naltrexone or disulfiram may provide greater benefit than acamprosate alone.

Nalmefene. Nalmefene (Revex) is an injectable opioid antagonist that is similar to naltrexone. It is generally used to reverse the effects of narcotics that are given during surgery. It is being investigated as an anticraving drug for alcohol dependence.

Aversion Medications

Disulfiram. Some drugs have properties that interact with alcohol to produce distressing side effects. Disulfiram (Antabuse) causes flushing, headache, nausea, and vomiting if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and may last from half an hour to 2 hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for 1 - 2 weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. The drug is more effective if patients have family or social support, including AA "buddies," who are close by and vigilant to ensure that they take it. A 2004 study that compared naltrexone with disulfiram during the course of one year found that 86% of patients treated with disulfiram remained abstinent compared with 44% of patients treated with naltrexone. However, patients treated with naltrexone had lower levels of alcohol craving.

Antidepressants

Depression is common among alcohol-dependent people, and it can be a significant problem in people who quit drinking. In fact, one 2002 study found that quitting drinking was associated with a fourfold increase in the risk for major depression. Antidepressants may be helpful, particularly for patients who have a history of depression. Experts reporting on the study suggested that treating these individuals with antidepressants as soon as they quit drinking may help prevent relapse. A 2004 review of clinical trials found that antidepressants had a limited effect on alcohol dependence and should be prescribed in combination with behavioral or pharmacologic therapies that directly address the addiction itself.

SSRIs. Selective serotonin reuptake inhibitors (SSRIs) target the neurotransmitter serotonin and are of particular interest in the treatment of alcoholism. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluvoxamine (Luvox). Studies indicate that these antidepressants may reduce cravings and desire for alcohol, even in selected people who are not depressed. Studies report reductions in alcohol ranging from 10 - 70% in people with alcoholism who take SSRIs. Research is under way to determine which individuals with alcoholism might best respond to SSRIs. For example, one study suggested that they may be more effective for men than women. Some may be specifically helpful for people with both alcoholism and certain anxiety disorders, such as social anxiety.

Designer Antidepressants. Drugs have now been developed that target other neurotransmitters, such as norepinephrine, alone or in addition to serotonin. They include nefazodone (Serzone), venlafaxine (Effexor), and mirtazapine (Remeron). Some research suggests they may have some benefits for treating alcoholism. However, nefazodone has been linked to increased risk for liver damage and should be used with caution by people with alcohol dependence.

Other Drugs

Topiramate. Topiramate (Topamax) is an anti-seizure drug used to treat epilepsy. It also helps control impulsivity. Early studies indicate it might reduce craving in patients with alcoholism, and may also help them stop smoking. Most side effects are mild to moderate and include mood swings and behavioral problems, dizziness, fatigue, visual disturbances, tremor, impaired concentration and thinking, weight loss and diarrhea, and a higher risk for kidney stones.

Odansetron.Ondansetron (Zofran) is ordinarily used to prevent nausea and vomiting due to chemotherapy. It also has actions that affect serotonin, a neurotransmitter that helps regulate alcohol's effects. In one study, ondansetron helped reduce drinking in people with early-onset alcoholism, although not in people who began drinking after age 25. These results suggest that this drug is helpful in patients with genetically related alcoholism, although not with alcoholism caused by other factors.

Review Date: 12/3/2006
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital