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Clinician’s Corner: Alcohol Relapse Prevention

Last week we discussed the role of common drugs such as – Librium, Valium, Ativan, Gabapentin and Tegretol for the treatment of alcohol detoxification.  Let’s now take a look of keeping our patients with alcohol use disorder from relapsing.

Alcohol Relapse Prevention Agents

Naltrexone (ReVia®)      

Mechanism: Blocks opioid receptors to reduce the pleasurable effects from alcohol. Increases abstinence days, reduces heavy drinking days and improves overall outcome.

  • BEST CHOICE (Pros): Abstinence from alcohol is NOT required for therapy. Helps for patients with high levels of cravings, especially in risky drinking situations. Helps prevent relapses into heavy drinking in patients who are not completely abstinent
  • CONTRAINDICATIONS: opiate abusers. Patients with severe liver disease. Can’t be given to patients currently receiving opioid therapy. Don’t use for kidney disease.
  • Patients should carry identification noting that they are on naltrexone in case of an injury requiring opioid therapy

Naltrexone Injectable extended release             —once a month

  • To avoid sudden opiate withdrawal, must be taken 7-14 days after last consumption of opioids; must not be actively drinking at time of injection. Good choice if patient compliance is an issue
  • Patient should stop drinking before Vivitrol injection.
  • May cause injection site reactions such as tissue damage.
  • If pain management is needed, Vivitrol blocks opioid receptors for 28 days.

Disulfiram (Antabuse®)

Mechanism: blocks liver enzymes that completely metabolize alcohol causing flushing, throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pains, palpitations, dizziness, low blood pressure and racing heartbeat.

Patient counseling points

  • Avoid alcohol in all forms
  • Clinically it reduces drinking days, but does not enhance abstinence.
  • Compliance is THE major factor determining efficacy of disulfiram.
  • Pros: for a person who needs emergency help to stop drinking NOW.
  • Does not reduce cravings.
  • CONTRAINDICATIONS: use of alcohol, coronary artery disease, liver disease, severe heart disease.

Acamprosate (Campral®)   333mg enteric coated tablets

Mechanism:  reduces the anxiety & other unpleasant effects of alcohol withdrawal. It is for patients who are abstinent and decrease relapse to heavy drinking. (Better effect with Campral and Naltrexone together)

  • Avoid if decreased kidney function.
  • Adverse Effects: Diarrhea, itching, depression, insomnia, heart side effects

Patient counseling points:

  • BEST CHOICE: for patients with significant liver disease, because it is excreted unchanged in the kidneys. Patients with SEVERE alcohol withdrawal symptoms. Patients able to initiate abstinence but have difficulty in maintaining newly regained abstinence. Most successful outcomes in studies when patients were abstinent of alcohol.  Better evidence for achieving abstinence than naltrexone.
  • ADHERENCE: adherence is the biggest challenge with acamprosate with three times a day dosing.
  • MAJOR SIDE EFFECT: diarrhea

Thiamine & Multivitamin

  • Chronic alcoholism interferes with the absorption of Thiamin and Folic acid
  • Thiamine (Vitamin B 1) 100mg daily to prevent brain swelling.

Treatment should begin at the beginning of alcohol withdrawal and continue at least through the alcohol withdrawal period.

Ensure folic acid is in multivitamin and prevent such complication as megaloblastic anemia

How long should treatment last?

  • Patients who maintain abstinence or adequately reduce heavy drinking, should continue psychosocial treatments for at least six months
  • Medication treatment should last one year, longer if tolerated.
  • Stability time increases as treatment time increases.

Unfortunately, on all therapies, half the patients relapse after 3 months.  Your Thompson pharmacist can help you or your loved ones maintain abstinence from drinking by helping you make sure the medication is taken.  We have a medication synchronization plan, where your prescriptions can be filled automatically, and picked up (or delivered) once a month.  We also can “pill-pack” your meds, at our Chestnut Avenue store to decrease confusion for administration.  We’re here to help you—because at Thompson Pharmacy… it’s all for YOU!