Dr. Eileen Barrett is Workit Health’s Senior Medical Director and VP of Quality. She’s passionate about supporting members with alcohol use disorder (AUD) in their recovery, and about spreading awareness about AUD and its treatment options. I sat down with her to talk about medications used to treat AUD.
If members tell you that they don’t want to include medication in their AUD treatment, how do you respond?
Dr. Barrett: The first thing I ask is, “Why?” I always want to lead with curiosity and openness, and that includes not assuming that I know what the member is thinking. Sometimes they have misinformation or disinformation that we can address, but I will never find out if I don’t start with curiosity and ask, “Why?”
Naltrexone and acamprosate are FDA-approved to treat AUD. How do you decide which to prescribe?
Dr. Barrett: Both naltrexone and acamprosate are highly effective for people who are seeking to cut back on or quit drinking.
In most cases, I’ll offer naltrexone first because it is effective, safe, and is taken just once a day. But I also consider other issues as well. For example, we look at other factors of the individual’s health. For example, if they use opioids (including prescribed medication to treat pain, buprenorphine or methadone to treat opioid use disorder, or illicit opioids such as fentanyl), naltrexone will not be a good fit because it blocks the effects of opioids. If they have advanced liver disease, naltrexone will not be best for them. And acamprosate isn’t a good choice for people with kidney disease. So health concerns can help us narrow down which medication is a better fit for that person.
Another important consideration is how they feel about taking medication and how easy it is for them to follow a schedule. Naltrexone is taken once a day, which is fairly convenient for most people. For acamprosate, the usual dose is two pills taken three times a day, which can be a lot to remember. Some people like the frequent reminders of their commitment to their recovery, but for others it feels like a burden.
I also look at a member’s past experience with AUD medication. I work with some folks who have tried naltrexone in the past and didn’t find it effective, so I might suggest acamprosate to them.
I also occasionally run into some superstition around acamprosate, because the most common dosage is 666 mg. Some people consider that number bad luck!
Aside from naltrexone and acamprosate, what medications are most commonly incorporated into AUD treatment, and what do they do?
Dr. Barrett: A lot of people with AUD have co-occurring conditions, especially depression and anxiety. So it’s common to treat those with medications (alongside behavioral health support and lifestyle changes). For depression, that might mean prescribing a selective serotonin reuptake inhibitors (SSRI) like sertraline (Lustral), paroxetine (Seroxat), or escitalopram (Cipralex). For anxiety, we often find that hydroxyzine (Vistaril) helps to take the edge off of their anxiety.
Gabapentin is primarily used to treat nerve pain, but it might be prescribed to help treat someone with alcohol use disorder. And we might recommend that someone take vitamin B1 (also called thiamine), as long-term drinking can lead to thiamine deficiency, which affects the brain.
Is there a typical length of time that people remain on medication for AUD?
Dr. Barrett: We usually start with a minimum of 6 months, and then evaluate how the individual feels. But there is no hard and fast rule about the duration of treatment. I generally recommend that members continue taking the medication as long as it is serving them. After all, these medications are much safer than resuming drinking would be so I fully support those who choose to take them indefinitely. To me, this is not unlike how people who have high blood pressure usually take their blood pressure pills indefinitely, as well.
Some folks reach a point in their recovery where they no longer feel that they need the support of daily medication, but might find it helpful once in a while. For example, if they’re going through a difficult time, or if they will be going into a stressful or triggering social situation. In that case, they can take naltrexone just when they need it. I call that a “pill in the pocket” technique.
What is the #1 misconception you’ve heard about medication for AUD?
Dr. Barrett: This biggest misconception I encounter is the belief that taking medication to treat AUD will make them sick. This is based on a medication that used to be commonly prescribed called disulfiram (Antabuse), which makes an individual miserably sick if they drink. It is no longer as commonly prescribed because people are likely to simply stop taking the medication rather than stopping drinking. Antabuse doesn’t address any of the underlying causes of returning to drinking—it doesn’t correct brain chemistry imbalance, doesn’t relieve cravings, and doesn’t help with irritability or insomnia … It just makes a person sick. Many of the people I talk to think that because Antabuse functions this way, all AUD medications will make them sick. But neither acamprosate nor naltrexone has that effect at all.
Many people believe that taking medication to support their recovery is “cheating” in some way. How do you address that?
Dr. Barrett: Again, I lead with, “Why?” Often discussing it will reveal that they heard a misperception in the media, in recovery spaces, or from loved ones. With the best intentions, it is possible to spread damaging myths about medication. Talking about these things lets us look at the facts instead of at the misinformation they heard.
Members that I speak with also often reveal some internalized shame that they aren’t “strong enough” or “tough enough” to fight through their AUD on their own. Discovering this lets us deconstruct this belief. After all, we don’t always have to power through the difficult things alone when there is help offered to us. We wouldn’t want someone with diabetes to suffer through when they could take insulin to treat their condition!
Final thoughts?
Dr. Barrett: I wish that more people knew that this support was available. I think so many people are struggling unnecessarily because they don’t know that medication is available.
Also, I want to emphasize that people who use medication to treat their AUD should incorporate other things to support their recovery: counseling, coaching, recovery groups, or mutual aid groups. AUD medication works best in conjunction with other forms of support.