Alcohol Treatment

prescribing for relapse prevention

What is it all about?

Relapse prevention medication can be a crucial part of recovery, however, it is important to remember that the benefits of pharmacotherapy last only for as long as medication is taken and always lifestyle change is at the heart of recovery. Improvements in the way existing medications are used would deliver the biggest gain in effectiveness. Practitioners need to consider: i) the best medication for the individual (rather than a favourite for all cases) ii) only prescribe to people who are in the maintenance stage of change iii) make sure the medication is continued for as long as significant relapse triggers exist - best if supervised.

  1. The choice of medication is controversial. The NICE CG115 guidance seems to favour acamprosate and naltrexone over disulfiram, which has stronger evidence for effectiveness. This may be because of the potential for more serious side effects with disulfiram but ignores the benefits to family and friends and the consequences for all involved of continued heavy drinking. It may be that abstinence is not seen as an important goal for some treatment agencies. It may be prescribers are unwilling to undertake the necessary medical checks.

  2. The three medications are pharmacologically different and this means that each is particularly well suited to a different use.

  3. The medications may have different effects in people with a different genetic makeup. This is still an area for research, but, for example, the effectiveness of acamprosate on craving varies markedly from one individual to another

The story of the three medications…

Disulfiram was the first of the relapse prevention medications to become available in the 1950s: initially it was seen as a treatment for all problem drinkers and fell from favour until its proper use was redefined in the 2000s.

Acamprosate and naltrexone started to be used in the 1990s. Acamprosate was very heavily marketed as an anti-craving drug, which appealed to internet savvy service users, and to prescribers who saw an easy fix. Naltrexone was originally used as an opiate blocker but has never became popular.

The different ways they work…

Disulfiram acts as a deterrent to drinking, acamprosate is said to reduce craving for alcohol (mechanism uncertain), and naltrexone reduces the positive effects of drinking alcohol.

Have a look at How Good is Alcohol Treatment and take a view on the place of each medication in relapse prevention.

This is how to do it…

Ideally a discussion about alcohol relapse medication will take place as part of planning detoxification, however, this is not always a time that service users want to think that far ahead, so be flexible. At some point your service user needs to know about the available medications and the evidence for their effectiveness. You could use the How Good is Alcohol Treatment page or give this as a homework task. It is probable that your service user will have searched the internet and already formed a preference. Disulfiram is the most challenging and revealing for both the prescriber and the service user, so rehearse your approach as if the drinking goal is abstinence and you consider disulfiram the first choice…

Practitioner: What are your initial thoughts about what you have read? [meaning from the homework or internet]

Service user: I’m really not sure.

[may suggest ambivalence or may not be used to homework or internet]

P: Not to worry - let’s look now.

[show the page on the website]

P: You see disulfiram, you might have heard of it as Antabuse, is going to be most effective for staying off the alcohol [share information from the website]. The idea with disulfiram is that you see yourself as a non-drinker - if you drink when taking the tablets then you get an unpleasant reaction, usually flushing and a pounding heart beat. This can be dangerous if you have a heart problem so, as you are over 40, we would check that out by doing an ECG, a heart tracing. Do you have any heart problems as far as you know?

SU: No nothing like that.

P: Good - the other thing to be aware of is that in very rare cases, 1 in 30,000, the liver can react to the tablets and become inflamed - a kind of hepatitis, which could be very serious. Lastly let me just check whether you have had any serious mental illness?

SU: Sometimes I get depressed with how my life is.

P: Okay, we can come back to that. What are your thoughts so far about Antabuse?

SU: I don’t like the sound of Antabuse just in case I did have a slip - I think the acamprosate is best for me.

P: Okay, so let’s have a look at acamprosate. [Look at the information on acamprosate on the website]. Whatever medication you take it is a good idea to involve your partner - what do you reckon to that?

SU: No - I can do this better myself.

P: What do you think your partner would want to do, to be of help to you?

[at this point you may be considering the strength of their motivation to abstain but have engaged with the SU so worth pursuing this conversation, and you will have another conversation if relapse does happen].

This is what you need to know…

Ideally people starting on an alcohol relapse prevention medication will be firmly committed to abstaining from alcohol, but a proportion will be ambivalent about abstinence and a proportion may have agreed a goal of moderation. Points to consider:

  • The likelihood of drinking

  • The high risk situations for drinking

  • Health contraindications

  • Service user preferences

Although these are pharmacological interventions, it is selling the belief in the drug that matters. Prescribers should be familiar with the Summary of Product Characteristics (SPC).

The evidence and the messages you want to communicate…

Disulfiram

✔︎ First choice for supporting an abstinence goal.

Family or friends can supervise taking the medication and they then benefit from knowing that drinking is not going to happen that day. Discuss how this will work in a collaborative way.

✔︎ Disulfiram also reduces the use of cocaine (by enhancing dopamine).

⚠️ Not to be used in pregnancy, with psychosis or significant cardiovascular problems. Advise of small risk of hepatitis and common tiredness (initially).

⚠️ Not to be used if there is a significant risk of drinking.

Prescribers check out the disulfiram SPC

Naltrexone

✔︎ First choice for taking in high risk situations or moderation goal.

Family or friends can check that the medication is taken or carried for use in high risk situations. Discuss how this will work in a collaborative way.

⚠️ Caution in pregnancy, liver or renal disorders. Advise of small risk of hypersensitivity to the tablets and common headache, insomnia, shivering and nervousness.

⚠️ Note: check if opiates might be present (naloxone test) before prescribing.

Nalmefene is essentially the same as naltrexone but licensed to lower drinking in low dependence individuals.

Prescribers check out the naltrexone SPC and nalmefene SPC

Acamprosate

✔︎ Use where other medications are contra-indicated.

Family or friends should check that the medication is taken. Discuss how this will work in a collaborative way.

⚠️ Not to be used when breast-feeding. Advise of small risk of hypersensitivity to the tablets and common skin rashes, reduced libido and gastrointestinal upsets.

⚠️ Note: dose is x2 tabs x3 daily which reinforces tablet taking behaviour.

Prescribers check out the acamprosate SPC

More pages about addiction treatment…