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Health Journal
A Prescription to End Drinking
From the Wall Street Journal of Mon, 15 Dec 2014 18:56:03 EST
How does alcohol affect the brain and what kinds of medications can help people cut down consumption of it? WSJ's Melinda Beck joins Tanya Rivero on Lunch Break. Photo: Corbis

New understanding of how alcohol affects the brain is prompting addiction experts to make a push for using medications to help people quit or cut down on excessive drinking.

For years, treatment has meant 28 days of rehab or a 12-step program. Success meant total abstinence. Only 1 in 10 of the 17 million Americans with a drinking problem ever tried.

There is also growing recognition that alcohol problems come in wide varieties, driven by a complex mix of genetics, life experiences and differences in how the brain handles stress and seeks rewards. As a result, experts say, the most effective treatments are highly individualized.

“The lonely person may respond differently than the party animal,” says neurobiologist George Koob, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is leading the effort to bring new, evidence-based treatments to more people.

Even the official terms used to describe drinking problems have changed in recent years. The separate categories of alcohol abuse (that is, getting drunk) and alcohol dependence (being addicted) have been replaced in the American Psychiatric Association’s DSM-5 diagnostic manual with a single spectrum of alcohol-use disorder that ranges in severity from mild to severe.

Answering “yes” to two or three of the 11 questions in an alcohol-related DSM-5 questionnaireindicates a mild problem, yes to four or five signals a moderate problem and six or more means severe.

New research also shows that about 30% of U.S. adults exceed the recommended daily limits for safe drinking (which are four drinks for a man, three for a woman) at least once a year.

Many of them—26% of adults—exceed those limits monthly and don’t show signs of drunkenness, but are at risk for health problems and developing addiction. About 3% are dependent on alcohol but still able to function and only about 1% are severely dependent, often with a family history of alcoholism and other psychiatric problems.

Experts hope that with more treatments available, people on the milder end of the spectrum will seek help earlier and avoid slipping into riskier drinking patterns.

“It’s a lot like depression. Sixty or 70 years ago, the only place you could go was a state hospital, and not many people went,” says Mark Willenbring, a former NIAAA official who now runs a treatment center, Alltyr, in St. Paul, Minn. “Then Prozac came out. Now three-quarters of people with depression get treatment.”

Dr. George Koob, left, and Dr. David Goldman, right, officials at the National Institute on Alcohol Abuse and Alcoholism, stand in Dr. Goldman’s lab in Rockville, Md.
Dr. George Koob, left, and Dr. David Goldman, right, officials at the National Institute on Alcohol Abuse and Alcoholism, stand in Dr. Goldman’s lab in Rockville, Md. Erin Bryant

The Food and Drug Administration has approved three prescription drugs to treat alcohol problems. But they are seldom used, largely because 12-step programs have dominated the treatment field, NIAAA experts say. All drugs used for this purpose have side effects. Most side effects—though not all—are mild.

Naltrexone works on opioid receptors in the brain’s reward system and blocks the pleasant effects of alcohol. It doesn’t work in everyone.

But studies show it is particularly effective in people of Northern European ancestry who have a specific gene variation. It doesn’t take a genetic test to find out, experts say. “Take a single dose and you’ll know right away if it’s working. It’s basically a buzzkill,” says Dr. Willenbring, who recommends it for people who are mildly dependent and want to cut down on their drinking.

He says one couple who sought help at his clinic typically consumed three bottles of wine together each night. They took naltrexone, went out to dinner nearby and had only half a bottle instead.

The FDA has approved a long-acting, injectable form of naltrexone with the brand name Vivitrol. A similar drug called nalmefene, or Selincro, is available in Europe specifically for people to take on an as-needed basis: perhaps before a party when they want to drink, but not to excess.

Spot a Problem

The American Psychiatric Association has a set of 11 questions to help people determine if they have an alcohol-use disorder, according to the DSM-5 diagnostic manual.

In the past year, have you:

  • Had times when you ended up drinking more or longer than you intended?
  • More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
  • Spent a lot of time drinking? Or being sick or getting over the aftereffects?
  • Experienced craving—a strong need, or urge, to drink?
  • Found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles or school problems?
  • Continued to drink even though it was causing trouble with your family or friends?
  • Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
  • More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area or having unsafe sex)?
  • Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?
  • Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
  • Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea or sweating? Or sensed things that were not there?

If you answer Yes to 2-3 of these questions, you have a mild disorder. Yes to 4-5 means moderate and Yes to 6 or more means severe.

Another drug, acamprosate, known by the brand name Campral, works to stabilize glutamate and other brain chemicals disrupted by long-term exposure to alcohol. That can reduce the irritability, anxiety and cravings that accompany withdrawal and can help people in recovery avoid relapsing, says the NIAAA’s Dr. Koob, a leading researcher in the neurobiology of emotion.

An older drug, disulfiram, trade-named Antabuse, blocks the body’s ability to metabolize alcohol, making people who take even one drink profoundly sick, with nausea, soaring blood pressure and blurred vision. A “black-box” warning, the FDA’s most severe, that comes with the drug says it should never be administered to a patient who is intoxicated or without his full knowledge.

Several drugs approved for other purposes have also shown promise in treating alcohol problems in recent clinical trials. Gabapentin, widely prescribed for epilepsy and shingles, appears to normalize levels of the neurotransmitter GABA in the brain’s emotional center, reducing anxiety and other withdrawal symptoms. In one small study published this year in JAMA Internal Medicine, people with alcohol dependence treated with gabapentin were far more likely to cut down or abstain completely than those taking a placebo. The NIAAA plans a larger, six-month trial, starting in 2015.

Topiramate, another epilepsy drug, also helped heavy drinkers reduce or quit drinking better than placebos.

And antismoking drug varenicline, known as Chantix, which cuts nicotine craving in smokers, appears to reduce alcohol craving in some drinkers as well. In a study of 200 alcohol-dependent adults published this year in the Journal of Addiction Medicine, those taking varenicline cut heavy drinking days a week by 22%. (Some people have experienced depression and suicidal thoughts with Chantix, according to black-box warning on the label.)

NIAAA officials say alcoholics are unlikely to get addicted tosuch medications, a concern of more traditional treatment programs in the past.

Some rehab programs have started adding medication to their treatment offerings. “We not only use it, we encourage it. If there’s something that can improve your chances of recovery, all the better,” says Joseph Lee, medical director for youth at the Hazelden Betty Ford Foundation, which uses naltrexone and acamprosate.

Alcoholics Anonymous, which claims over two million sober alumni, expresses no opinion on the use of medications to get or stay sober, according to a public information coordinator. Some participants stress relying on the 12-step method instead, which includes admitting being powerless over alcohol.

NIAAA officials say such programs still hold an important place in alcohol treatment. But they note that newer behavioral treatments try to empower patients instead, and focus on developing skills to stay sober.

In motivational interviewing, for example, therapists help struggling drinkers identify positive reasons to change their behavior. “Say a patient really loves to surf. A therapist might say, ‘Dude, if you spent less on alcohol, you could move closer to the water,’ ” Dr. Koob says. “It often works well to get somebody started.”

Cognitive behavioral therapy can help people understand the thoughts and emotions they associate with drinking and develop other means of coping. “Like, what do you do when there’s a cocktail party with work colleagues? You can hold a sparkling water and lime and still enjoy yourself,” Dr. Koob says.

Such exercises can be done one-on-one or in group sessions, and are increasingly available in Web-based or mobile versions. One smartphone app called A-CHESS includes relaxation programs and emergency contact numbers and is equipped with a GPS program that warns patients if they are nearing a high-risk area that includes a bar they used to frequent.

Researchers are also studying ways to alter the brain pathways involved in alcoholism.

“Over the last 25 to 30 years, much of the neurocircuitry of addiction has been identified,” opening up new targets for interventions, says David Goldman, chief of the NIAAA’s neurogenetics lab. One method being studied for alcoholism is deep brain stimulation with implanted electrodes. Another is transcranial magnetic stimulation, which modifies the electrical function of the brain from outside the skull, non-invasively.

Even a brief conversation with a primary-care physician can help people with mild alcohol problems from slipping into riskier patterns, studies show. “Sure, you may lie if the doctor asks you how much you drink, but on the way home, maybe you’ll think you should cut back a little,” Dr. Koob says. “We advocate abstinence, but…the goal is to stop excessive drinking.

Write to Melinda Beck at

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