Margaret can’t remember how her car ended up on its roof not far from her Delta, B.C., home, except that she had been drinking before slipping behind the wheel.
Hanging upside down by her seatbelt, her head submerged in water, it’s a miracle she didn’t die. A retired firefighter who happened to be driving by saved her. He jumped into the ditch and held her head out of the water through the crushed windshield until paramedics arrived.
At first, Margaret, who asked that her full name not be used, drank only after work — just a glass of wine while preparing dinner, then a second, and then soon a full bottle.
She started drinking at work. She eventually lost her retail business. She was at risk of losing everything else, relapsing in and out of AA, when a doctor introduced her to a drug called naltrexone, which helps block some of the euphoric effects, the socially lubricating appeal, of booze.
When Margaret took one of those pale yellow pills an hour before drinking, wine suddenly didn’t have the same pull. She used to think about her second glass before she was barely into her first. Not any more.
“Halfway through my first glass, I lose interest,” she said. Today, she takes naltrexone whenever she and her husband have company and she thinks she is going to drink. “I don’t feel safe without it.”
Naltrexone is arguably more effective than popular anti-cholesterol medication. According to a 2014 meta-analysis, for every 12 people who are treated, one will not return to heavy drinking; while 233 people at increased risk of cardiovascular disease would need to be treated with cholesterol-lowering statins for two to six years to prevent one cardiovascular death, according to a systematic review.
But few people who could benefit are ever prescribed naltrexone, or two other drugs formally approved by Health Canada to help people with a problematic pattern of alcohol use. The reasons are many, including old, cultural attitudes that frame addiction as a moral failing and not a medical problem, financial and logistical barriers and too few doctors with the training and exposure needed to help people manage their relationships with an enormously popular drug.
The medical profession professes to be compassionate and science-based. “Yet, here’s this big gap in care,” said Dr. Jeff Harries, a family doctor in Penticton, B.C., working to improve the care of people with alcohol use disorders. “It’s so bizarre.”
About 80 per cent of Canadians drink. Fifteen to 20 per cent of Canadians exceed official low-risk drinking guidelines (no more than 10 drinks a week for women, and 15 drinks a week for men). A further 18 per cent engage in heavy drinking — five drinks or more for men, and four drinks or more for women on one occasion at least once a month in the previous year.
The price of this over indulgence is more than 3,000 deaths attributable to alcohol each year; another 80,000 hospitalizations due to conditions wholly caused by overconsumption of alcohol — intoxication, withdrawal, delirium, cirrhosis of the liver, alcohol-induced pancreatitis, hepatitis, liver complaints — higher than the number of hospitalizations for heart attacks. And the rates of harm are rising faster for women than for men.
Canada may be in the grips of a deadly opioid crisis, but the bigger beast is our relationship with booze. “Vastly greater numbers of people are affected by alcohol, and dying by alcohol-related disease,” said Dr. Sharon Cirone, a family physician who works in Toronto and Sioux Lookout with a focused practice on addictions and mental health.
Even Canada’s recently revamped food guide hammers home the dangers of drinking at unhealthy levels, including an increased risk for cancers of the colon, breast, larynx, pharynx, oesophagus and liver. Yet counselling remains the mainstay of treatment. A 2017 study found that, of 10,394 Ontario adults younger than 65 who were treated in hospital for a booze-related visit over a one-year period — and who were eligible for public drug benefits — only 37 (0.4 per cent) were given naltrexone or acamprosate in the year after their hospital visit.
Until recently, doctors in Ontario had to fill out special request forms to get access to the pills. “That was a major problem,” said Dr. Sheryl Spithoff, an addiction medicine physician at Women’s College Hospital in Toronto. But there’s also the lingering view that this is something that can be cured with sheer willpower alone, she said.
The oldest approved drug for alcohol use disorders is disulfiram, better known as Antabuse, a near 70-year-old medication that interferes with the way the body breaks down ethanol. When taken with even small amounts of alcohol, the side effects are seriously unpleasant: headaches, difficulty breathing, facial flushing, palpitations, chest pain, vertigo and vomiting. “For decades, the only treatment for alcoholism was an instant, crippling hangover,” Shaughnessy Bishop-Stall wrote in his recently released book, Hungover: The Morning After and One Man’s Quest For a Cure.
Another, called acamprosate, seems to work by restoring the balance of brain chemicals thrown off kilter by chronic, heavy drinking. It reduces cravings, as well as the insomnia, restlessness and anxiety of coming off alcohol.
Studies have shown these, as well as a handful of other drugs doctors are using off-label (meaning for unapproved purposes), such as the anti-seizure drug gabapentin, can be moderately effective in helping people drink less, and less often.
Yet, “Most doctors get their beliefs about treating alcohol use disorder from the same source the rest of us do — AA,” said Mike Pond, a West Vancouver-based psychotherapist and co-author, with his partner Maureen Palmer, of Wasted: An Alcoholic Therapist’s Fight for Recovery in a Flawed Treatment System. “Doctors don’t use their ‘medical brain’ with this disorder the way they do for others.”
These medications potentially can help a wide range of people get back some of the control they have lost
The best studies suggest the success rate of AA, which demands, in addition to abstinence, a vow for members to surrender their lives and “will to the care of God,” is between five and 10 per cent, Dr. Lance Dodes, former director of Harvard Medical School’s substance abuse treatment program at McLean Hospital in Boston, wrote in his book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. A review by the much respected Cochrane Collaboration of randomized studies conducted between 1966 and 2005 concluded that “no experimental studies unequivocally demonstrated the effectiveness of AA” or other 12-step facilitated approaches for reducing alcohol dependence or problems.
AA is very much aligned with the binary approach to addiction — you’re either an alcoholic or you’re not, and, once an alcoholic you can never drink again.
People see things in a more nuanced way now, said Tim Stockwell, director with the University of Victoria’s Canadian Institute for Substance Use Research. “There is a continuum of severity, and probably everybody who drinks with any regularity is probably depending on alcohol to a degree. It’s just how far we go down that line.”
Yet the majority of treatment programs are predicated on that all-or-nothing ideology. Pond, of West Vancouver, prefers the any-positive-change approach. “And it’s always client driven.”
“Some people come in and say, ‘I don’t really want to quit.’ So I say, ‘Let’s take a moderation management approach, a harm reduction approach. We’re going to use meds, and we’re also going to use therapy,’ and then we look for trends: Is there a diminishment in consumption?”
What’s needed, Pond and others say, is a new standard of care, one in which family doctors can deliver brief (five to 15 minute) counselling sessions, appropriate medications and referrals to other resources as needed, especially in severe cases. Advocates want mandatory training on alcohol and substance abuse — how to screen for it, how to manage it — in family medicine and emergency medicine residency programs. They also say drugs like naltrexone, which costs around $6 a day, should be covered by every provincial and territorial drug formulary.
During the worst of his drinking days Pond went to an emergency room 32 times. “Most of the times the response I got was, ‘you need to go to AA, you need to go to rehab.’” Palmer once picked up a bible of treatment centres that listed hundreds of rehab clinics offering everything from equine therapy, to angel therapy. Rarely was a word mentioned about medications to help with cravings or urges.
The first family doctor Margaret turned to for help before she was referred to Jeff Harries said only, “What are we going to do with you?” Margaret was dumb-struck. “I was expecting some kind of help.”
Naltrexone is the same compound, used in a different formulation, that’s given to people in the grips of an opioid overdose. It’s an opioid antagonist — an anti-opioid.
With alcohol, the first few drinks stimulate the production of endorphins that bind to opioid receptors in the brain’s reward centre, delivering an initial boost, an everything-is-good-with-the-world feeling. But then that initial euphoria flattens out, Pond said. The brain keeps wanting it back, sending the message: Drink more. “The naltrexone kind of blunts that right from the get go,” Pond said. People don’t feel so euphoric.
“It doesn’t ruin the enjoyment of the alcohol, but there is less positive reinforcement to go onto the second, or third drink,” Cirone explained. It helps slow things down, decrease cravings and “give you space in your brain, your thoughts, to plan things differently and maybe even make different decisions.”
Doctors don’t use their ‘medical brain’ with this disorder the way they do for others
Naltrexone doesn’t work for everyone, and genetics may matter. But it’s the most studied medical treatment for alcohol dependence. A Cochrane reviewfound that more people who took naltrexone reduced their heavy drinking days compared to those who took an identical-looking placebo.
Studies have also shown that brief counselling interventions by doctors can help people reduce binge drinking and excessive weekly booze intake. But here is where things start to fall apart: A national physician survey in 2010 found that fewer than half of family medicine residents in Canada said they had any residency training in substance abuse; only 18 per cent said they intended to provide care for substance abusers in their practice.
There are some promising changes. The University of Toronto and other medical schools are adding more addiction education to their curriculum. Harries says there has been a noticeable drop in visits to ER for people with alcohol use disorders in his area because more doctors “know these meds can be part of how to successfully treat this condition.” The College of Family Physicians of Canada and Canadian Centre on Substance Use and Addiction has produced an online resource to help doctors screen for and address risky drinking in their patients. Even something as simple as taking a liver function test, feeding the results back to the patient and following up once or twice “is in itself a very powerful intervention,” said Stockwell, of the U of Victoria. In Ontario, people can also access RAAM, or “rapid access addiction medicine” clinics, walk-in clinics for adults struggling with alcohol or opioid-related addictions that provide free prescription meds.
Pills don’t address the underlying issues that drive some people to drink, like childhood trauma, anxiety and depression. And, in cases where people are facing massive social or legal problems, people with explosive drinking patterns whose livers are giving out, “for sure it’s better to have the goal of abstinence,” said Dr. Bernard Le Foll, a clinician scientist at the Centre for Addiction and Mental Health.
But for others, “these medications potentially can help a wide range of people get back some of the control they have lost,” Le Foll said.
https://nationalpost.com/news/pills-can-help-people-control-risky-drinking-so-why-arent-doctors-prescribing-them
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