Medication assisted treatment for alcohol dependence
Withdrawal can be undertaken in a variety of settings. In South Australia, this could be at home with the help of a GP and supportive friends/family, in hospital or in an inpatient unit (eg Drug and Alcohol Services South Australia’s Withdrawal Services). For further information about alcohol withdrawal options, contact the Alcohol and Drug Information Service (ADIS) 1300 13 1340 or visit the Treatment options for drug and alcohol issues page.
Any medications prescribed by a doctor for managing withdrawal should be taken as directed. It is important not to take medications without telling your doctor or to start drinking (or taking illegal drugs) while still taking the prescribed medication.
Medications used in managing withdrawal symptoms
Diazepam (Valium, Antenex, Ducene)
Diazepam belongs to the group of drugs called benzodiazepines (PDF 124KB). They have a similar action in the brain to that of alcohol so are good at relieving many of the symptoms of alcohol withdrawal. Clinical studies have shown this group of drugs is the safest and most effective treatment available.
Diazepam is usually prescribed for the first few days (up to a week), often in reducing amounts. This ensures the person does not develop benzodiazepine addiction; long-term use is not appropriate. Higher doses may be safely used in an inpatient setting, rather than in the home. Diazepam is usually taken several times a day in the beginning.
Diazepam (and other benzodiazepines) increases the effects of alcohol and other sedatives so the person should not drink while taking them. Benzodiazepines also affect ability to drive or operate machinery.
Thiamine is one of the group B vitamins (vitamin B1). It is important to the normal functioning of the nervous system. Chronic alcohol drinkers do not absorb it well from the gut and often have a poor diet. Some symptoms of thiamine deficiency include memory disturbance, confusion, double vision, poor coordination and unsteadiness.
Thiamine is better absorbed by injection and this is recommended at the start of treatment. Once a person has stopped drinking they may be given oral thiamine tablets.
Further information and advice
Alcohol and Drug Information Service (ADIS) 1300 13 1340
ADIS is a telephone information, counselling, and referral service.
Drug and Alcohol Clinical Advisory Service (DACAS)
DACAS provides general practitioners and other health professionals direct telephone access to a specialist drug and alcohol medical officer.
Telephone: (08) 7087 1742.
Stopping drinking (and going through withdrawal) is just the first step in the process of giving up - it takes time both to become dependent on alcohol and to give up.
Attending counselling and/or using other supports (eg AA - Alcoholics Anonymous) are very important to help reduce the likelihood of a relapse back to drinking – and increase the chance of success.
In addition, there are a number of medications available that may help.
How it works: Acamprosate works on the brain - it acts on some of the same receptors and transmitters (messengers) as alcohol. It can help to restore the chemical imbalance in brain cells caused by long-term heavy alcohol use. Acamprosate can help to reduce craving for alcohol, making it easier to resist a lapse to drinking - studies have shown it doubles the chances of staying abstinent.
Who can take it and who can't: A person must have alcohol dependence and want to stop drinking. It is recommended that acamprosate is started after a person has stopped drinking. It should not be taken by pregnant or breastfeeding women or people who have kidney disease or severe liver disease.
How often, how long and side effects: Acamprosate tablets are taken three times daily (usually two tablets each time) at meal times (making it easier to remember). Most people do not experience any side effects from acamprosate; if they do occur, the most common are diarrhoea and nausea or a skin rash. It takes about a week for the drug to reach its full effect and it can be continued for as long as needed (usually up to 12 months). There is some evidence that the benefits may continue even after stopping taking it.
Availability: Acamprosate is subsidised by the government (PBS), and is available on prescription from a doctor. The doctor needs to phone for an authority - the person must have alcohol dependence with a goal of abstinence and be in a comprehensive treatment program. The doctor is only allowed to prescribe one-or-two-months supply at a time but can continue prescribing for as long as needed.
How it works: Naltrexone also acts on the brain - it blocks the effects of alcohol on the opioid receptors that cause the high or lifting of mood experienced when drinking alcohol. As a result of taking naltrexone, craving for alcohol is reduced and drinking is much less pleasurable. There are some people who are particularly sensitive to the opioid effects of alcohol - they may have a strong family history of alcohol problems. Studies have shown that naltrexone halves the chances of relapsing to heavy drinking.
Who can take it and who can't: A person must have alcohol dependence and want to stop drinking. It is recommended that naltrexone is started after a person has stopped drinking. It should not be taken by pregnant or breastfeeding women (unless there are exceptional circumstances) or people who have significant liver disease. It cannot be taken by people who are regularly taking or are dependent on opioids (it blocks their effects and can cause withdrawal).
How often, how long and side effects: Naltrexone tablets are taken once a day (1 tablet). Most people do not experience side effects from naltrexone; if they do occur, the most common is nausea. Naltrexone starts to work within an hour of being taken and wears off within 72 hours of stopping. It can be continued for as long as needed (usually up to 12 months).
Availability: Naltrexone is subsidised by the government (PBS), and is available on prescription from a doctor. The doctor needs to phone for an authority - the person must have alcohol dependence with a goal of abstinence and be in a comprehensive treatment program. The doctor is only allowed to prescribe one or two months supply at a time but can continue prescribing for as long as needed. Note: Naltrexone is only subsidised for the treatment of alcohol dependence, not opioid dependence.
How it works: Disulfiram causes very unpleasant effects as a result of what it does to the metabolism of alcohol. In the body, alcohol is converted in the liver, firstly to a chemical called acetaldehyde. Usually acetaldehyde is quickly converted to carbon dioxide and water. Disulfiram blocks the enzyme that drives this step. When someone taking disulfiram drinks alcohol, acetaldehyde accumulates in the blood stream causing reactions such as flushing, headache, nausea, difficulty breathing, chest pain and collapse. Studies have shown that disulfiram may assist a person to remain abstinent from alcohol, especially if someone observes them take it.
Who can take it and who can't: A person must have alcohol dependence and want to stop drinking. Disulfiram must be started after a person has stopped drinking (at least 24-48 hours after the last drink so there is no alcohol in the bloodstream). Disulfiram cannot be taken by those with severe liver, kidney or heart disease, a psychotic illness or in pregnancy. There are a number of other medical conditions that also pose a risk, so it is not usually prescribed as a first option.
How often, how long and side effects: Disulfiram tablets are taken once daily, dissolved in water (usually 1 tablet). Side effects may occur and range from mild to severe. There can also be interactions with other medications and any foods containing alcohol. Disulfiram starts to work within 24 hours and the effects last for at least a week after stopping taking it. It is continued for as long as needed (usually about 12 months).
Availability: Disulfiram is not subsidised by the government and the full cost is borne by the patient. It can be prescribed by any doctor but is not usually considered as a first-line treatment.
Medications: getting it right
Combinations of medications
Acamprosate and naltrexone is a safe combination, but the evidence about the effectiveness of the combination is conflicting.
Acamprosate and disulfiram is a safe combination and may improve abstinence and craving, but there is no good evidence to support this.
Naltrexone and disulfiram are not recommended as a combination as both could cause liver problems.
If people suffer from depression or anxiety that contributes to their alcohol dependence, it may be necessary to have treatment for this at the same time. This should be discussed with the treating doctor.
The decision regarding the medication to be used should be based on the advice of the person's doctor who will take into account the person's experience, their medical history, family history, craving and triggers for drinking. It's an individual choice; sometimes if one medication doesn't seem to help, an alternative will.
Be realistic in your expectations – medication is not magic. Changing behaviour takes time and effort and is unlikely to occur merely as a result of taking a particular tablet. It is essential to involve other supports for change (eg counselling, AA - Alcoholics Anonymous).