Last month, in an effort to make it easier for health professionals to identify and treat patients with heavy drinking and alcohol-use disorders, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) released Helping Patients Who Drink Too Much: A Clinician's Guide. One major difference in the 2005 guide, which replaces an earlier 2003 version, is the recommendation that medications be considered in addition to traditional therapies as part of the treatment process.

According to the new guide, the three FDA-approved medications—disulfiram (Antabuse, Odyssey Pharmaceuticals), naltrexone, and acamprosate (Campral, Forest Laboratories)—have been shown to be effective adjuncts to the treatment of alcohol dependence, and clinicians should consider adding medication when treating a patient with active alcohol dependence or one who has discontinued drinking in the past few months but still has problems such as cravings or slips.

According to NIAAA, a division of the National Institutes of Health, drinking becomes too much when men drink five or more standard drinks per day (or 15 or more per week) and women drink four or more drinks per day (or eight or more per week). An estimated 8% of adult Americans, more than 17 million, suffer from alcohol dependence or abuse.

More and more physicians are now prescribing medications instead of, or in addition to, psychotherapy or traditional treatment programs. In fact, contrary to approaches of the past, a patient taking naltrexone may continue to drink—in lesser amounts—due to the drug's ability to block opiate receptors in the brain that are involved in the rewarding effects and craving for alcohol. This new view may be a far cry from the belief that abstinence is the only way, but many physicians believe it is a more realistic goal for many patients.

"This will make alcoholism a mainstream problem that family practitioners deal with," said Bankole Johnson, M.D., Ph.D., chairman, department of psychiatry at the University of Virginia, who oversees clinical trials for some of the drugs. One intent of the NIAAA in updating the guide was to enlarge the target audience to include mental health clinicians, making it easier to screen and treat patients, Johnson said.

The guide warns that disulfiram is contraindicated in patients who continue to drink due to the buildup of acetaldehyde and a reaction of nausea, flushing, and tachycardia. Acamprosate is approved for patients who are abstinent; however, it may lessen the severity of relapses if a patient does resume drinking. Although it is not known why, naltrexone appears to work better in patients with a family history of alcohol dependence.

The safest course for someone who has developed dependence is still abstinence, but it is best to individualize goals for each patient, according to both the new guidelines and Brian Fingerson, R.Ph., president, Kentucky Professionals Recovery Network. "I believe that the 12-step recovery works the best for most," he said, referring to Alcoholic Anonymous' well-known program. But he also has clients who have been prescribed naltrexone and topiramate (Topamax, Ortho-McNeil) as adjuncts to their recovery effort. Topiramate, while officially approved for use in migraines and seizure disorders, has shown some off-label usefulness in reducing cravings for alcohol. Side effects include cognitive problems, such as difficulty concentrating or remembering words.

Other drugs under study for use in alcoholism are ondansetron (Zofran, GlaxoSmith-Kline),aripiprazole (Abilify, Otsuka), and baclofen. Drugs in development include rimonabant (Acomplia, Sanofi-Aventis) and a once-monthly injection of naltrexone called Vivitrex (Alkermes Inc.), which could improve patient compliance.

Fingerson, who is also an adjunct assistant professor at the University of Kentucky College of Pharmacy and a faculty member at the University of Utah School on Alcoholism and Other Drug Dependencies, is not sure how much impact these guidelines will have on pharmacists. He has found that pharmacists don't have enough "face" time with patients to allow for questions on alcohol use but believes "there is a tremendous need in pharmacy and medical school for more education on substance dependency."

Print copies of the new guide are available from NIAAA at (301) 443-3860 or on-line at www.niaaa.nih.gov.