Alcohol Use Disorder

Harm Reduction in Alcoholism: Part two

“But I don’t want to stop drinking completely, I like to drink socially”. Social drinking for those trying to recover from chronic alcohol use is unlikely. After all, everyone starts out drinking socially, but end up unable to avoid escalation of consumption. However, if you are under the care of an Addiction Medicine Specialist, you certainly should be able practice harm reduction. Harm reduction is a long process with a lot of work for the patient and the specialist. But let’s consider it- let’s consider Harm Reduction.

Harm Reduction

(Taken from Harm Reduction Coalition)

“Harm reduction is a set of practice strategies and ideas aimed at reducing negative consequences associated with alcohol and other substances. Harm Reduction is a movement for social justice built on a belief in, respect for, the rights of people who use alcohol and other drugs. It’s for you too”

(Taken from ncbi.nim.nih.gov website)

“Harm reduction is a public health strategy developed for persons with substance abuse problems (alcohol) for whom abstinence is not feasible. Harm reduction approaches have been effective in reducing morbidity and mortality. Abstinent means no drinking at all- no alcohol. There are medications to use that may help one stop drinking altogether if he or she chooses. Medications are designed for those who want to become abstinent.
(Taken from HealthLink BC)

Harm Reduction includes positions of various federal and local government organizations (SAMSHA, NIH, Surgeon General) and smaller local organizations who have taken a lead from these policy making organizations for the nation down to local community’s health centers. They all aim to keep the people safe, minimize injuries and deaths from high risk behavior from psychoactive substances and of course alcohol. Harm reduction recognizes that high risk behavior (injections, over consumption of alcohol) may continue despite the risks. Below are some examples of support services for harm reduction available for alcohol and psychoactive substances:

• Not allowing alcohol retail establishments close to schools.
• Raising the drinking age to 21.
• Restricting where alcohol can be consumed.
• Outreach and education services in communities – Narcotics Anonymous or Alcohol Anonymous are examples of groups that are ran independently by persons who use substances or alcohol and who identified gaps in their treatments.
• Impaired driving prevention campaigns that create awareness of the risks of driving while under the influence of alcohol and other illegal substances.

There are many benefits related to Harm Reduction for alcohol and substance abuse:

• Reduce alcoholic hepatitis- the number one reason for liver transplants.
• Reduce alcohol poisoning (overdose) deaths and other early deaths among persons who use alcohol
• Reduce unemployment from lost work time

Harm Reduction is the easiest way, in my opinion, for those who fail at abstinence. If one adheres to the doctor’s instructions, listens to what is being said, forgets about preconceived ideas (we don’t know what we don’t know) and sticks to the long term plan, it should work. There are a couple books that show exactly how it works. You can’t do it alone. It is used in any stage of alcohol use. It is open to all persons. Harm reduction is an empowering mode of treatment for alcohol misuse or abuse.

Caveats

Some people may not want to quit or may not be able to quit. They may continue to relapse over and over again. Harm Reduction reduces the use of alcohol and helps bring down death rates and morbidity. Harm Reduction has been researched and the results shows that Harm Reduction does not encourage drinking. Harm Reduction potentially lowers the cost of medical care in the form of lower hepatitis and liver transplants.

BACLOFEN. (Lioresal, Gablofen) in Alcohol Addiction

Baclofen can be used with Harm Reduction, cocaine abuse, opioid abuse, and pain management as well.

Credit is given to: Ameisen, Olivier MD (“The End of My Addiction“. 2005, 2008 France) written in French this book is now translated into English and can be found on Amazon.
Baclofen Treatment for Alcoholism website (Baclofentreatment.com). Dr. AMANDA STAFFORD
Frontiers in Psychiatry- Addictive disorders. (frontiersin.org)
PubMed.gov. Addiction Biology 2006 Sept; 11(3-4):270-88.
Recommended reading: All You Need to Know About Baclofen; by Dr. Phillip Thomas
The B4a Baclofen Handbook; by Dr. Phillip Thomas

Most patients, general public, medical staff/officers are not familiar with Baclofen’s off label use unless they work with conditions such as: multiple sclerosis, spinal cord injuries, or disease of the spinal cord, pain spasms or stiffness caused by these conditions. Patients usually have a hard time finding a physician who is willing to work with you using baclofen. But Baclofen has been used officially or off label to treat alcoholism in Italy, Australia and France. In these countries, baclofen is one of the first line medications used and recommended by health authorities. It is used off label in the US. It is very inexpensive, generic and a medication that has been around for a very long time.

In 2008, I began to seriously study alcoholism treatment and came across a cardiologists’ book “The End of My Addiction”. This cardiac surgeon had a severe alcohol use problem. He describes in his book how he would drink until blackouts- he had absolutely no control over consumption. Nothing helped his condition. The top rehabilitation clinics and hospitals in the world could not help him stay in recovery. So he did what any scientist would do, he found his own cure after all the mainstream attempts failed him. In his book, he describes how Baclofen cured him- yes, cured him. The cure rate for alcoholism is dismally low. In fact, it is so low for some familiar self-help groups, that their cure rate isn’t well published. My interest in Baclofen grew as a result of studying his research and his treatment of his own drinking habits.

Some of my patients wanted to practice Harm Reduction in drinking. So I began to work closely with Baclofen off label in collaboration with these patients. I found that by using Baclofen with other treatment strategies had more success than without using baclofen. For some patients, baclofen did not work or only worked for a little while. I expect to have even more successful outcomes. In my experience, as an addiction medicine specialist, I have found that Baclofen is nearly the most effective off label treatment for patients with the disease of alcoholism.
(These are my medical opinions and not meant to give anyone medical advice. Always check with your physician.)

Dr. Amanda Stafford finds that, in the traditional view or in the general consensus of family, lay persons, and even medical personnel, alcoholics will always be alcoholics and will never be able to drink in a normal or safe way. Perhaps this undercurrent belief system was promulgated by Alcohol Anonymous, where the goal should always be total abstinence. In some societies, this is very tough to do especially in a culture where drinking is deeply ingrained. Now I don’t mean drinking at a neighborhood pub or corner bar, but normalized alcohol consumption with meals (dinner wine in Italy or France as examples). Alcohol can absolutely be consumed in a moderate manner on occasion, just a beer or a glass of wine. But, in my opinion, only with the help of medical oversight. That means by any means agreed upon and adhered to by your specialist by sticking with the program as long as it takes in the specialist judgment. A wise person told me that “if one could be a social drinker, on one’s own accord, he or she would not need to read this.” Help is always available.

WILL BACLOFEN HELP ME?

Yes. From what I know a resounding yes if you stick with the program. Okay, not everyone, but most. But know that it is used off label and it may have side effects for some like drowsiness, dizziness, weakness, tired feeling, headache, insomnia, nausea, constipation, increased urination). There is an abundance of medical evidence and studies on it in the US and in new research in France, Italy and Australia.
Working at the National Cancer Institute and National Institutes of Health in DC as an undergraduate, I was involved in research that evaluated different cancer treatments using rats. Animal research is the most unbiased research that one can hope for because animals don’t lie about how they feel. Have you ever touched your dog’s painful leg or sore spot? Your dog loves you, but you will quickly learn that your dog forgets everything for an instant and will give you a nip, yes you, the one who feeds them. Okay, so here’s your proof: If one performs an experiment on animals and gives them something for pain, in some way, you can ask the poor creature how it felt afterwards, to get an indication on the treatment’s effectiveness and you will get a truthful answer. Again, it may come in the form of showing general playfulness or a suppressed response to, let’s say, pressing on a sore or painful spot or behaviorally.

What does the animal prefer? If one places two bowls side by side, alcohol in one and water in the other and then get yourself some alcohol preferring rats, or the P-rat. (Bell RL, et. al. The alcohol-preferring P-rat.. Models of excessive alcohol drinking). The alcohol-preferring P-rat was developed from selective breeding to study ethanol (alcohol) drinking behavior and its consequences (Yes, we bred alcoholic rats from birth). These findings indicate that the P-rat can be effectively used in models assessing alcohol-preference, a genetic predisposition for alcohol abuse and /or alcoholism, and excessive drinking using protocols of binge-like or relapse-like drinking.

First the P-rats were given some baclofen. There was a bowl with plain water and a bowl with only alcohol in the other. Initially the rats preferred the alcohol bowl. Because, well that’s what they were breed for, to drink alcohol. But then these alcoholic P-rats preferred the water. They stopped preferring the alcohol. This worked with a cocaine experiment too. Don’t forget the binge drinking. This is one of the toughest complications I find in my alcohol use disorder patients. In the rats, baclofen worked for binge P-rats as well. Yes, there are binge drinking rats too.

Baclofen is a good treatment option. But it does require expert medical attention. Typically a patient will request treatment with Baclofen. As mentioned above, baclofen may cause side effects that should be carefully monitored. This means that the patient should have close follow up with the physician, since physicians are allowed to prescribe off label. There may be issues of over consumption of the pills, or behavioral problems may surface. One should have good kidney function because baclofen is excreted by the kidneys. Liver function doesn’t matter much since the liver doesn’t play a role in baclofen metabolism. Generally, baclofen is safe in the majority of cases.

In my practice patients do not have to be abstinent. But they are counseled that the use of baclofen and alcohol both can cause extra sedation, dizziness or other psychoactive symptoms. I usually do not get complaints about problems using alcohol and baclofen. I offer treatment with standard alcohol treatments medications first. This is a good practice. However, other medications have usually already been tried. The dosing is determined individually with differing factors being considered. Since alcohol can be toxic to the bodies systems (the skin, nervous system, heart, kidney, pancreas, liver, gastrointestinal track “from the mouth to the anus”, spleen, brain, a general health evaluation is indicated. But this should not delay the treatment.

Baclofen relieves the wanting or craving for alcohol (like seeing chocolate cake on the table but you’re not allowed to eat any, you get that wanting feeling, the craving for it). Sometimes the craving or the wanting completely resolves. There should be total relief from the desire. Some patients have commented “Doc, I feel indifferent to alcohol after taking baclofen- I can take it or leave it.” Baclofen helps to cut down on the number of drinks significantly. Baclofen helps make binge drinking less severe to no binge drinking at all. Baclofen can help detox from alcohol dependence because its use of the same brain receptors that are used for benzodiazepines (valium, alprazolam) detoxification. It binds to the same receptor but a different spot on the receptor (subunit). So withdrawal or the possible alcohol withdrawal syndrome is attenuated.

Some baclofen patents aim for harm reduction or abstinence. It’s your choice. Just make the healthiest choice. Where one ends the journey is difficult to predict. If what you are doing or what you are trying hasn’t given you the results that you want, then get out of the box and give baclofen a try. What is there to loose trying baclofen? I believe you will have better results trying this off label method. Baclofen will make consuming alcohol less pleasurable. No, this is not like Antabuse but, as with Revia, you will not get as much reward from those drinks anymore. (Revia is discussed later) As with some of the other methods I use for alcoholism, baclofen is not magic. One has to follow a sensible path. If you choose harm reduction and your drinking has changed, precaution is still indicated in your alcohol consumption. Don’t consume too much because relapse is still possible even with baclofen. You still have to give the brain time to heal its alcohol addictions’ neurological pathway. Early into sobriety the pathways are not strong enough for some casual drinking because the liking of alcohol may be too strong early on in some. But taking a drink is allowed while using baclofen. It is feasible to drink occasionally or at safe levels while using baclofen. However, this is not a place half way between heavy drinking and normal drinking. That is not what we mean. It has to be truly normal drinking freely chosen and in social situations – not driven by craving, compulsion or using alcohol as a quick fix for pain or stress. (Dr. Amanda Stafford). She also recommends, and I concur, it takes time to get to this point, months or even years. The brains addiction nerves must be well controlled with the help of baclofen and well healed without compulsive drinking or binging. The executive functions of the forebrain should be in charge again instead of the primitive brainstem which seeks only pleasure and satisfaction. Controlling triggers, anxiety, social or work situations are all extremely important in maintaining sobriety.

Vivitrol in Alcoholism

I have patients show up to my office for treatment for opioid addiction that are absolutely opposed to ever putting another opioid into their body again or want to stop using alcohol and ask me:

• Will Vivitrol help?
• I hear Vivitrol works for my addiction without the risk of getting hooked on the medicine itself?
• Will it help my pill taking?
• Will it help my heroin injection habit?
• Will it help my alcoholism?
• Is it covered by most health insurance?
• Can I receive the injection in your office?
• Do your patients have successful outcomes?
• Can I get off of it and have no withdrawal?
• May I stay on it as long as I need?

The answer to all of the above is YES- absolutely yes! This is a very excellent option for treatment for addictions. Vivitrol is used in both alcohol and opioid addictions. Sources:-vivitrol.com-google.com

Alcoholism treatment with vivitrol is very successful. Vivitrol is one of the few medications with a high level of success. One may choose a pill form or injection form of this chemical. The pill form is called Revia and is discussed below. Vivitrol is a brand name for naltrexone, generic. It blocks the effects of alcohol. It takes away the pleasurable aspects of drinking. One does not get sick when drinking when on the injections. You can drink but you won’t enjoy it as much because it somewhat decrease the release of dopamine. Dopamine gives one that pleasurable feeling (like the burst of pleasure from taking that first bite from warm German chocolate cake). In fact, you may be wondering if there are studies on vivitrol and rats. The answer is yes. There are also gambling studies using rats. That’s right, we have rats that are bred (born) to gambling.

The vivitrol injection is given in the buttock thigh region once a month. Patients must come to the office one time per month for the injection. The medicine works for 30 days up until the next injection. If possible, a different spot on the region is chosen each time. Vivitrol works best while receiving counseling or at least in self-help or church group. Private counseling and CBT works as well. As long as the patient is not taking opioids, have not taken opioids for at least 7 to 14 days, it is okay to receive the injection right away. This usually is not a problem with alcohol consumers. But, if one uses this for opioid dependency it is recommended that opioids had not been consumed for 7 to 14 day. A challenge test may be given to assure compliance with instructions.

Is vivitrol safe? Yes, but patients with liver disease should use caution because the naltrexone can cause liver damage or cause chemical hepatitis. Also, vivitrol may cause other side effects. The possibilities of side effects should be discussed with your addiction medicine specialist.

Revia in alcoholism (Revia= Naltrexone)

Sources : accessdata.fda.gov. the-sinclair-method.com Dr. David Sinclair, Phd.. patents.google.com “The Cure for Alcoholism: The medically proven way to eliminate ……”
Roy Eskapa, Phd.
Alcohol addiction. Claudia Christian, et el. ( One Little Pill: prime video )
Alcohol, the Brain, and Behavior. Alcohol Res Health. 2000; 24(1) 12 to 15.

“Truly a Harm Reduction method for the extinction method to work, alcohol is consumed at a decreasing rate or continued consumption together with Naltrexone (Revia) for the technique to work to become De-addicted. “
Dr. Brunson

Revia, a form of Naltrexone, is a favorite medication that I use in the treatment of alcoholism and it is the one that gets the most surprising results amongst my patients. Surprisingly, it was not well known in the US as a treatment for alcoholism when I first began prescribing it. Now, it is better known in the US and is now used often, most frequently in Europe. Revia is usually given to patients on a once daily regimen. “Take the pill daily and let’s just see if it works on your drinking behavior” as is commonly prescribed. I studied an alternative method or a variation of this theme. Pharmacological extinction or the extinction method, yes that one, where Pavlov used the salivating dogs.

The Sinclair Method

In my clinic harm reduction is, in my opinion, the only method that I can explain scientifically as it relates to the brains mechanism in treating alcoholism. The success rate is the highest in medication assisted treatment and harm reduction. It is my first choice if the other methods have been tried and have failed. Usually patients show up to my clinic after they have tried the standard treatments.
(This is for informational purposes. Not medical advice. See an addiction Medicine physician for medical advice on this topic).

“The Sinclair Method has a 78% success rate”

How to have a successful outcome with the Sinclair Method

My patients had the best success by:

• Coming in to the clinic as recommended by the physician for every visit. Until there is a mutual agreement to disengage from treatment.
• Take the revia as agreed upon (this is a very inexpensive medication).
• Keeping a record of all alcohol consumption (each drink and what you drank and the amount of the drink- mini, glass, can,750ml, etc.
• Keep a record of cravings.

As they became de-addicted, they consumed less and less alcohol until the program was complete.
After 3 to 4 months and sometimes up to 6 months you may be cured. That is, if you stick with the program.
(Disclaimer: Being cured is not a guarantee).

Listen to “Claudia Christian talks-“The Sinclair Method” from TEDxLondonBusiness School”. And the DVD “One Little Pill”.

Imagine coming upon a knee high grass field perfectly smooth without tracks- one that has never been traversed. Now walk across the field and then back. Now repeat about as many days you drink alcohol in say, many months. Stand back and look at the path you made. It is deep semi and permanent. If you stop walking across and back, you will notice new grass will filling in the path. The path will not be noticeable any longer.

The brain has a memory. The memories come to the surface to consciousness by neuronal paths or many tiny threadlike nerves/paths/roads. When one takes a drink, the body remembers that and sends a signal up/across the path (nerve), reaches a stop sign, pauses for a split second, and then the signal opens a dam/nerve synapse/gate across the path which releases dopamine. That feel good chemical that we love to feel so much.

Generally, when alcohol is consumed it travels through the stomach to the blood then to the brain. A chemical reaction occurs in the brain and signals for a release of some feel good chemicals to make us want to continue drinking, or gives a reward. If you take something that blocks the feel good reward chemical so that when we drink alcohol we don’t get that good feeling reward, eventually we do not find anything compelling about taking a drink. Waste of time. I can take it or leave it. Maybe once in a while a drink is taken. You are cured. You have extinguished drinking from your life at this point.

The following is for the technically and scientifically gifted. Feel free to jump ahead to the next topic

What happened in the brain?
Alcohol research current reviews: 2000:24(1):12 -15

When alcohol enters the brain, neurons communicate with each other. They connect through neurotransmitters. At the end of each neuron are receptacles/receptors (like a plug and socket) which receive the neurotransmitter (put the plug in the socket) that alcohol caused to be released from the beginning of the chemical reaction. When the neurotransmitter plugs into dopamine and serotonin sockets or receptors, chemicals are released- dopamine among others. Dopamine is the reward. The feel good chemical we all have in our body and so like to feel it.

“I tell my patients dopamine is good for us. But not too much like coconut cream cake, you should only eat a little portion at a time and only once in a while. You get a release of dopamine when you eat chocolate, kiss your wife/husband, go to the movies, get your pay-check (well sometimes) sit down to eat for family meals. All these situations during your life time causes a release of dopamine in your body. The dopamine then causes that pleasurable feeling. But, what if you found something that you really like? I mean something that gives you a super boost of dopamine and an extremely desirable sensation or feeling, one that is off the chart. So much that the little burst of dopamine you get from sitting down for a family meal seems like a pesky blip on the scale. Why settle for that when one can get a super release of dopamine by consuming something else, like a pill or some drinks? One begins to not show up for those family meals, celebration, and hugs. That is exactly what happens with drugs, alcohol etc. All those daily little positive “feel good blips” on your dopamine scale that you get throughout the day (from hugs, passing school tests, sitting with family, winter-holiday celebrations) become unimportant because they no longer raise that reward chemical, dopamine, high enough to maintain an adequate good feeling all day. But, there are other scale busting things (like methamphetamine, cocaine, and alcohol) can give you the super-high level that you crave. It’s addictive.

Liking what dopamine does for us is not bad; it is a normal function to feel it. Sometimes we feel low energy and just cannot figure out how to increase our baseline energy level. So we discover alcohol or other things in the environment that assuredly get us to a higher energy level, higher, high. This may be okay to once in a while (not by taking drugs of course) but this behavior can get out of control. Every time we tell ourselves “okay, that’s it, no more” we realize that it’s not so easy and we need help changing the behavior. The Sinclair Method (Naltrexone/Revia) is one treatment strategy that is found to be remarkably helpful and one strategy that has studies that are readily available for anyone to review. (See Vivitrol, baclofen, cannabis also)

Acamprosate (Campral)
Sources:
americanaddictioncenters.org Taking Campral for Alcohol Abuse and Addiction
Mason and Heyser. Acamprosate: A prototypic neuromodulator in the treatment of alcohol dependence. CNS Neurol Discord Drug /Targets. 2010 Mar, 9(1): 23
(This is not meant to give medical advice. Just for information. See your Addiction Medicine Physician)

Campral is a pill that was first used in France called Aotal in the 1980’s. It has been used in the US for a couple decades. It has been shown that it works well for overuse of alcohol abuse. Campral is usually taken after drinking has stopped to help maintain ones sobriety. It is more effective when taken with other medications that are used to treat alcoholism. Campral is the 333 medication. That is taking 2 of the 333mg 3 times a day. One of Campral’s strengths is that if there is already liver damage (say, hepatitis or cirrhosis) Campral may still be taken (like Baclofen). It may also be taken if on methadone. However, if there are kidney problems, close follow up visits are needed to adjust the dose if needed because the medication levels may become too high in the body in renal insufficiency. Since it takes about 5 days or more to get to effective levels after one has stopped drinking, the build-up period and withdrawal from alcohol period can become intolerable for some. A sedative hypnotic may be used here, or some other stabilizing medication- so combination therapy may work best with campral.

Mason and Heyser, 2010 concludes that Acamprosate (campral) is well suited for treating a broad population of alcohol-dependent patients given it an excellent safety profile observed in clinical trials, along with the ways the body metabolizes it and the manner in which it is eliminated from the body pharmacokinetics and pharmacodynamics characteristics. It is also accepted as a first line treatment for alcohol use disorder.

Prozac (Fluoxetine) has been used in the treatment of alcoholism. However, is comes with many side effects when used in this manner. The risks outweigh the benefits. There are other medications that can be used without the side effects. It is not high on my list of the medications that I use for alcohol use disorder. On a more positive note, Prozac is a selective serotonin re uptake inhibitor (SSRI). It antagonizes the re-uptake of serotonin in nervous system synapses. This led to reduced reporting of episodes of drinking, reporting of having fewer drinks in a sitting, and more days in abstinence. Effective in moderate drinkers. It may be helpful in those dually diagnosed with depression and alcoholism or other mental health problem. So this patient population did not suffer with alcoholism alone but had a co-existing mental health disorder- usually self-medicating their depression with alcohol.

TOPAMAX

Very well mind.com. How Topiramate is used for the Treatment of Alcoholism. 2019
Journalofaddictionmedicine.com
Topapomax (topiramate) is not a first line medication for alcohol use disorder as recognized by the FDA, but is by the Department of Defense and veterans affairs. We physicians have found it helpful for alcoholism treatment and drug addiction, such as cocaine. So we try it for efficacy- physicians may use pharmaceuticals off label if they believe they are in the best interest of the patient or is medically appropriate.

Resources : NIH, NIAAA. ASAM. AMA.