The Levees Are Holding: The Go-to Medications for Alcohol Use Disorder

By Paul R. 05/23/19
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A lot has been said about the role of Antabuse, Naltrexone and Campral in recovery from alcohol dependence (the debate sometimes also extends to Topamax). The road to recovery is never linear, so, in general, whatever works is better than the alternative, even if it is pure placebo. The latter two of the three drugs act deep in the brain (Campral as a GABA modulator and partial NMDA antagonist and Naltrexone as an opioid antagonist, also now widely used off-label as an ethanol antagonist), whereas Antabuse hits where it hurts most – the liver by removing liver’s capacity to process alcohol with all the resulting unpleasant consequences. Antabuse is all about aversion, whereas the other two regulate cravings.

In my experience, none of them work in isolation, and even when coupled with each other. Therapy, such as Cognitive Behavioral Therapy, as well as a balanced diet, exercise, hydration, sleep and prompt attention to any co-morbidities such as depression or anxiety are an absolute must. Holistic approach, in other words, is the name of the game. The spiritual component is likewise important and is an integral part of the process and it can be manifested, again, through meditation, support groups, fellowships (AA, CDA).

Sounds easy enough? Well, it's not. The kicker is that each component in this recovery concoction has to be fresh. The whole dish is dependent on the robustness of each of its ingredients and skipping one results in the entire thing going sour fast and right into the abyss of a renewed use, which brings us back to where we started – the medications.

AA allows for the importance of medications in recovery, as do most of other recovery groups (SMART and, obviously, the Sinclair Method) and medical professionals, however, they are still viewed by many as a crutch, an impurity, a shortcut. The questions then – inevitably – becomes who is right. Let us leave the disease model aside for now (that logical chain is straightforward: disease requires medication, one would not try to control diabetes with a prayer, so the disease of addiction is no different) and focus on prevention. As with any complex issue, especially those that have to do with the deep unknowns of the mind, the truth is somewhere in the middle. I know plenty of addicts who recover using the spiritual tools of, say, NA, yet at the same time, many simply cannot go on without either the anti-cravings medications or aversion agents or both. Once again, we are NOT talking here about other mental health issues, such as depression.

Since Naltrexone and Campral have a more subtle and nuanced effect (cravings reduction is literally a humongous slope with a multitude of gradations depending on age, dosage, length of use, etc.), let us look at Antabuse and try to assess its actual value in recovery from alcohol dependence. This medication is century-old. It has proven to act as a potent aversion agent for ethanol and if the dose is right, will not allow an alcoholic to drink, no matter what.

For starters, it negates the euphoria and causes overall intense feeling of physical distress (I recall it felt as if my heart was beating in my throat making my head recoil in unison. To say that I felt unwell is to say nothing – it was torturous, even evil). To think that a doctor would prescribe something like that to another human being is pretty unsettling, considering the Hippocratic Oath and all. Yet it works (end justifies the means). I could not keep down a single drink, and the feeling of impending heart attack or stroke or both had etched in my memory forever.

Of course, the main issue here is that in order to use Antabuse one has to … use Antabuse, i.e. take it regularly pretty much in perpetuity. Many don’t. I recall I stopped a few times and counted out 72 to 120 hours to start the alcohol intake again. Presumably, force-feeding medications to an addict is inhumane, even if that ultimately saves that addict’s life. Or is it? Is it then a balancing act or a stark choice, a panacea or a grim, devoid of any humanity solution?

I am not a doctor and under no circumstances I advocate taking any medication without it first being approved by a licensed MD, however, I have come to believe that if Antabuse is taken routinely and either willfully or with the help/under the supervision of a loved one or a nurse, it virtually guarantees sobriety, even when that sobriety feels unwelcome.

And please, spare me the “dry drunk” argument – in my view, that is the biggest misnomer, even a hoax. The restlessness and irritability that comes with sobriety for an alcoholic are parts of the post-acute withdrawal syndrome (PAWS), which is a medically-documented fact. Once the body recovers from the initial onslaught of ethanol, the mind follows and the depression alleviates, unless, of course it was accompanying substance abuse all along. Then, it is a separate issue that has nothing to do with what Antabuse is immediately for – to keep BAC at 0.0% and, thus, facilitate the most expedient passing of PAWS.

Sure, there is a significant interplay between mental health and addiction, and depression and anxiety must be promptly dealt with in the proper context of, for instance, substance abuse, yet, once again, the “dry drunk” ruse needs to be called out for what it is – a made-up, science-averse i.e., conveniently used by so many recovery groups to control their “parishes.” Antabuse, coupled with proper diet and exercise, as well as mindfulness (prayer, CBT) can lead to a full recovery and to state otherwise is simply to go back in time to continue to live a lie.

 

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