DETOXIFICATION: Alcohol detoxification is medically supervised withdrawal. Medically supervised withdrawal is accomplished by giving a long acting drug that works on the same receptor system as alcohol. The drug is given in tapering doses down over a period of a few days to a week. The class of drugs called benzodiazepines are used for outpatient detox from alcohol. I like to use Librium, as it is a very long acting. It continues to taper itself down after the medication is stopped due to it’s long half-life. Also, alcohol and Librium are both sedatives, so caution must be used, as combining the two can result in overdose.
DO I ACTUALLY NEED DETOX?: Many patients come to their first appointment asking for detox. Frequently, after doing a history and exam with vital signs, we find that detox is not needed. Alcohol withdrawal is diagnosed for the most part by hand tremors, abnormal vital signs (elevated heart rate and elevated blood pressure), feeling generally ill, anxious, and irritable. In order to develop a withdrawal syndrome, the body needs to have a physical dependence on alcohol. With physical dependence, a characteristic withdrawal syndrome will develop as the blood alcohol level progressively goes down to zero. Physical dependence to alcohol develops when a person drinks throughout the day and evening. Many of the patients that come to see me only start drinking after work. They do not drink during the day, so they do not become physically dependent on alcohol. Isolated complaints of anxiety and irritability are not symptoms that require treatment with a Librium taper. These symptoms do require treatment with other types of medications, which do not have the risk of overdose when combining a benzodiazepine with alcohol in the event of a relapse
ALCOHOL WITHDRAWAL IS A SERIOUS MEDICAL CONDITION: Alcohol withdrawal should be taken very seriously and treated with caution. The first and most important reason for detox is to try and prevent life and limb threatening complications. Two life-threatening complications of alcohol withdrawal are grand-mal withdrawal seizures and delirium tremens (“DT’s”). Delirium tremens is alcohol withdrawal with hallucinations and unstable vital signs. Outpatient medical detox from alcohol is not safe for everyone. If you are interested in outpatient detoxification from alcohol, Dr. Locketz will assess your safety for this type of treatment. Please note that the first appointment is an evaluation only. Medications are never prescribed at the first appointment. Please also note that you must stay with a responsible adult friend or family member for the first 24 to 48 hours of your detox. That person will be administering your medication to you.
STOP OR MODERATE YOUR DRINKING: There are now a different number of medications that are available to help people reduce or stop their drinking.
GABA DRUGS: Baclofen / Neurontin / Topamax / Campral
Drugs that affect the GABA system in the brain can be very effective for the treatment of alcoholism. One of the receptors that alcohol stimulates is the GABA-A receptor. Stimulation of the GABA-A receptor is responsible for the calming and anti-anxiety effects of alcohol. Sedative medications such as Valium also stimulate the GABA-A receptor. In fact, alcohol can be thought of as liquid Valium, and Valium can be thought of as freeze dried alcohol.
So far, baclofen is the most effective GABA medication that I prescribe for alcohol addiction. I continue to be amazed by how effective this medication is for many people who identify themselves as alcoholics or heavy drinkers. Many patients who start baclofen describe a complete loss of cravings, as well as a complete indifference to alcohol. About half of the patients for whom I prescribe baclofen stop drinking completely within the first few days of starting the medication. Other patients significantly reduce their drinking to a healthier level. I have found it to be helpful for some patients who want to comfortably moderate their drinking. They control the alcohol, the alcohol does not control them.
Baclofen is actually a muscle relaxant that has been around for a long time. It works for the treatment of alcoholism in two ways. First, it treats anxiety by acting on the GABA-B receptor. Second, baclofen attenuates the brain neurotransmitter dopamine, which is responsible for the euphoric and rewarding effects of alcohol. GABA-B receptors and dopamine receptors in the reward pathway of the brain are intertwined. This gives baclofen a very unique mechanism of action, and is the reason such dramatic results can be seen when treating patients who identify as alcoholics or heavy drinkers.
Baclofen basically works by treating anxiety and emotional states of tension and stress. In my medical practice, I treat many high functioning people with stressful jobs who will not drink during the workday. However, drinking will start almost immediately when the workday is over. The alcohol (“liquid Valium”), provides relief from the anxiety, tensions, and stressors from the day. Baclofen works by treating these symptoms without the intoxication of alcohol. With this type of biological treatment for alcoholism, patients are able to stop or reduce their drinking, while feeling good at the same time.
Neurontin is a seizure medication that is also used for chronic pain, anxiety disorders, and addiction to alcohol. Neurontin can be thought of as working at the GABA-A receptor. Like all GABA drugs, Neurontin essentially works to put alcohol addiction into remission by treating anxiety and emotional states of tension and stress. So far, I have found Neurontin to be the second most effective GABA drug that I prescribe. Neurontin is prescribed as a medication to be taken three times daily, and it is also taken as an as needed medication for cravings. Neurontin can also be taken as a prophylactic dose for “high risk” situations, such as work or social functions where many people will be drinking. If being able to drink socially is the goal for treatment, some patients are able to moderate their drinking with the help of Neurontin.
Topamax is a seizure medication that is also used for weight loss, migraine headaches, and addiction to alcohol. It works at the GABA-A receptor, so it works for alcohol addiction by treating anxiety and emotional states of tension and stress. Topamax also works at glutamate receptors, which are increased in people that are alcoholic or heavy drinkers. Glutamate is a neurotransmitter that is excitatory, so an excess of glutamate contributes to feelings of anxiety and irritability. Topamax can be thought of as blocking the effects of glutamate. Topamax is taken as a nightly or twice daily dose, and a steady blood level of the medication is achieved within a few days.
Campral was specifically developed and FDA approved for the treatment of alcoholism. It acts at GABA-A and glutamate receptors. I have found Campral to be the least effective of all of the GABA drugs. This is ironic, as it is one of the few medications that was created and FDA approved specifically to treat addiction to alcohol.
NALTREXONE AND THE SINCLAIR METHOD
One of the receptors that alcohol stimulates is the mu-opioid receptor. This is the same receptor that is stimulated by narcotic pain medications such as Percocet and Vicodin. Activating this receptor causes a release of dopamine in the brain. Dopamine is a neurotransmitter that is responsible for feelings of pleasure, reward, and euphoria. Naltrexone is a medication that is a mu-opioid receptor antagonist, meaning that it blocks the receptor. If a person drinks while taking this medication, the alcohol will have a much less pleasurable effect.
In the United States, naltrexone is prescribed as one 50mg tablet that is to be taken every day. At the same time, patients are told to completely abstain from alcohol. With the Sinclair Method, developed and widely used in Finland, naltrexone is prescribed in a different way. Patients are told to continue drinking as they normally would. At the same time, they must always take one 50mg tablet of naltrexone one hour before drinking Just as important as the one hour rule. the naltrexone must never be taken on non-drinking days. The main goal with the Sinclair Method is to achieve the process of extinction for cravings for alcohol. With extinction, when a behavior which was pleasurable and positively reinforcing, becomes less pleasurable and less positively reinforcing, the behavior gradually and naturally stops occurring. This gradual process eventually leads to less cravings and less desire for alcohol. The goal with the Sinclair Method is to eventually enable people to either stop drinking or to moderate their drinking.
I have found the Sinclair Method to be the most effective way to use naltrexone. The actress Claudia Christian used the Sinclair Method to put her alcoholism into remission. She then founded the C3 Foundation to provide education, support, and resources for use of the Sinclair Method. The C3 Foundation can be found at www.cthreefoundation.org. “One Little Pill”, a documentary movie about the Sinclair Method, and narrated by Claudia Christian, can be found at the C3 Foundation website as well.
Dr. Locketz also facilitates referral and entry into various forms of recovery treatment such as SMART Recovery® and Intensive Outpatient Treatment (IOP) at local addiction treatment centers. He offers non-12 step help with alcohol and drug addiction treatment. When inpatient drug and alcohol addiction treatment is warranted, Dr. Locketz will facilitate entry into an inpatient facility.