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Drug Therapy for Alcohol Dependency: What's the Issue?

Arthur Caplan, PhD

Arthur Caplan, PhD is chief of the Division of Medical Ethics at the NYU Langone Medical Center.

I.

A few years ago, at a conference held at the University of Pennsylvania on the treatment of alcoholism sponsored by the ScattergoodEthics Program, an odd dilemma came into focus. This dilemma persists and makes it very clear why more attention has to be paid to ethics in the treatment of mental illness.

Many of the speakers pointed out that there was ample evidence that there are drugs that are effective in taking away the cravings to drink that promote relapse in alcohol dependent persons. Naltrexone, which is sold under the trade names Depade and Revia and in an extended release version called Vivitrol, has been shown in many studies by many groups in the United States and other nations to be a very safe drug that is highly effective in treating alcoholism. Yet, relatively few programs that treat chronic alcoholics use the drug. Why?

In most situations where there are drugs to ‘treat’ diseases they don’t get used because they are difficult to take, have nasty side-effects, cost too much or simply don’t work very well. Not so for Naltrexone. It works, it is safe and it does not cost all that much. A three-month supply runs about $750 which is peanuts compared to the price of in-patient drug addiction programs or other drugs routinely used to treat cancer, myasthenia gravis, Parkinson’s, or migraines.

How strong is the evidence for the efficacy and safety of Naltrexone? There were two large-scale, randomized trials of Naltrexone that showed very impressive results in 1992. Since that time many studies have been done which confirm its efficacy in reducing the frequency and severity of relapse to drinking. In 1999 Dr. Robert M. Swift wrote at the conclusion of a major review article in the New England Journal of Medicine,

“Drug therapy should be considered for all patients in whom alcohol dependence is diagnosed who do not have medical contraindications to the use of the drug and who are willing to take it. Of the several drugs studied for the treatment of alcohol dependence, the evidence of efficacy is strongest for naltrexone…” (Swift, Drug Therapy for Alcohol Dependence, NEJM, 1999:1488)

In 2006 the NIAAA of the NIH reported that,

“the medication naltrexone and up to 20 sessions of alcohol counseling by a behavioral specialist are equally effective treatments for alcohol dependence when delivered with structured medical management, according to results from "Combining Medications and Behavioral Interventions for Alcoholism" (The COMBINE Study). Results from the National Institutes of Health-supported study show that patients who received naltrexone, specialized alcohol counseling, or both demonstrated the best drinking outcomes after 16 weeks of outpatient treatment."

Naltrexone works just as well as intensive behavioral counseling in getting people to stop drinking or cut back on their drinking.

II.

So what is going on here? After more than 15 year of evidence in leading journals a lot of people with alcohol problems are not being offered Naltrexone or other drugs. Even if those professionals treating alcoholics don’t want to give up on counseling and social support why aren’t more providers prescribing Naltrexone, along with counseling, to help control the craving for alcohol?

The answer is ethics or, more particularly, ethical attitudes about drinking and what needs to be done to stop alcohol abuse.

For many decades the treatment of alcoholism in the United States has been built around the generation of sufficient will-power in the drinker to stay abstinent and sober—for a lifetime. Alcoholics Anonymous and many other out-patient and in-patient treatment programs try to give the abusive drinker the tools of self-regard and self-control that will let them stop drinking.

There is nothing wrong with that approach, but it does not work for everyone. Might some people do better with a combination of drug therapy along with counseling or social support for a time? And if counseling or in-patient care are not options due to cost issues or access problems then shouldn’t Naltrexone be tried on its own when that is a possibility or the only possibility?

The only possible reason for the failure to make greater use of Naltrexone and other drugs useful in the treatment of alcoholism is moral. Americans including American health care professionals often see alcohol abuse as an issue of willpower not biological addiction. The cure for a lack of will is therapy that can stimulate and rebuild willpower—something not associated with drugs but with counseling along with community and peer support.

There may well be aspects of personal responsibility and willpower that shape the emergence of alcohol abuse for many or even the majority of those who abuse. But, it is not ethical to adhere to the view that efficacious drug therapy cannot be utilized as part of treatment because drug therapy is seen as either antithetical to self-control or because it is seen as some sort of ‘short cut’.

There are some ethicists who hold the view that only authentic or earned experiences are legitimate (Kass, 2002; President’s Council 2003). If you don’t suffer and sweat then you have not earned your right to abstinence. Or perhaps if you don’t suffer and sweat then your abstinence will not endure. These arguments are not persuasive and may actually be doing grave harm in the treatment of alcohol abuse.

There is no evidence that the efficacy of Naltrexone is less than that of counseling and peer support based interventions. Nor is there any evidence that both cannot be combined successfully. And there is no basis at all for the claim that somehow using a drug as therapy makes the result any less legitimate than any other form of treatment. To hold this view is to argue that only those who survive the flu or HIV or polio through natural immunity deserve to live while those who take vaccines or drugs are somehow ‘cheating’.

Some of those who favor the greater use of Naltrexone and other drugs in the treatment of alcohol abuse tend to believe that if they provide the evidence of safety and efficacy then changes in treatment will follow. But, after more than fifteen years of compiling evidence that change has not happened. If it is to happen, if drug therapy is to play a greater role in the treatment of alcohol and other addictions in the future then it only will be a combination of scientific evidence and ethical argument that permit this to happen.

 

 

Further reading

CP O'Brien. Prospects for a Genomic Approach to the Treatment of Alcoholism. Arch Gen Psychiatry, February 1, 2008; 65(2): 132-3.

L. Kass. Life Liberty and the Defense of Dignity. San Francisco, Encounter Books: 2002.

RF Anton. Naltrexone for the management of alcohol dependence. NEJM, 359,7, 2008: 715-21.

RM Swift. Drug therapy for alcohol dependence. NEJM, 340, 1999: 1482-90.

SH Williams. Medications for treating alcohol dependence. American Family Physician. 72, 9, 2005: 1775-80.

The President's Council on Bioethics. Beyond Therapy: Biotechnology and the Pursuit of Happiness. Washington, D.C., October 2003.

Arthur Caplan, PhD is chief of the Division of Medical Ethics at the NYU Langone Medical Center.

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