Topiramate (Topamax) Topiramate is an anticonvulsant that affects voltage-dependent sodium channels, GABA transmission, and glutamate receptors. It has been found to reduce alcohol use in patients with alcohol use disorder and is the preferred second-line option in patients with seizure disorders. Some have shown that topiramate has mild to moderate effectiveness in reducing the percent of drinking days, reducing heavy drinking days, increasing abstinence, reducing cravings, and improving quality of life, but results have not been consistent in displaying these outcomes. 204,213 Topiramate is initiated at 25 mg daily and can be titrated up slowly over 8 weeks to a maximum dose of 300 mg per day; titration helps to minimize the risk of adverse effects. Adverse effects associated with topiramate include cognitive impairment, sedation, weight loss, gastrointestinal side effects, headache, fatigue, dizziness, depression, and paresthesias. Since weight loss occurs in 4 to 21% of patients, topiramate may be preferrable in obese patients. Some patients find the cognitive impairment associated with topiramate to be intolerable, as it affects word finding abilities and can impact psychosocial interactions. Rare but serious side effects include nephrolithiasis, acute angle-closure glaucoma, and metabolic acidosis. It may be beneficial to monitor renal function and cognitive status prior to initiation. 204,213,215 Gabapentin (Neurontin) Patients who previously failed first-line treatments can consider gabapentin for alcohol use disorder. Gabapentin is an anticonvulsant that is structurally similar to GABA and may modulate excitatory neurotransmitters in the brain; it can be used off-label for alcohol use disorder. Clinical trials showed that doses of 900 to 1800 mg per day have shown efficacy in reducing the percentage of heavy drinking days, increasing abstinence rates, reducing drinking frequency and quantity, and improving mood, cravings, and sleep. Common side effects associated with gabapentin include dizziness, drowsiness, fatigue. Gabapentin is primarily eliminated through the kidneys, and patients with renal impairment require dosage adjustments. There have been reports of addictive potential with gabapentin; providers should be alert to potential misuse. 204,216 Psychosocial Therapy Along with any of these medications, one or more psychosocial interventions are recommended, including cognitive behavioral therapy, behavioral couples therapy, community reinforcement or group therapy, motivational enhancement therapy, and 12-step programs While the quality of evidence supporting these interventions is low, they can modestly improve adherence, reduce alcohol consumption, and assist in recovery of patients with alcohol use disorder, particularly when used in combination with one another or with pharmacological therapy.
Psychosocial therapy may be particularly beneficial in patients with co-occurring mental health conditions such as anxiety or depression. 216 Cognitive behavioral therapy (CBT) helps patients adjust their behavior and thinking related to alcohol use and encourages patients to change other areas of life that are related to their alcohol use. Patients are taught to track activities and thinking in order to identify the consequences, such as alcohol use episodes and cravings. Then techniques are taught to help the patient change behaviors and thoughts that contribute to alcohol use in order to improve interpersonal functioning, mood, coping skills, and social support. Treatment plans include structured practice outside of therapy sessions, such as self-monitoring, scheduled activities, thought recording and practicing interpersonal skills. Cognitive behavioral therapy has been shown to be effective in patients with alcohol use disorders compared to minimal psychosocial interventions. 216 The community reinforcement approach is a type of cognitive behavioral therapy that focuses on environmental factors that influence the patient’s behaviors. Environmental factors can be greatly influential on a patient’s addictive behavior, so this approach uses social, recreational, family and occupational events to support the patient in changing their behavior. This helps the patient develop healthy behaviors that allow a sober lifestyle to become more rewarding than one that involves alcohol use. Some forms of the community reinforcement approach provide incentives for positive behaviors, such as taking medication, attending treatment sessions, or abstinence. 216 Behavioral couples therapy is useful for patients in relationships, and focuses on reducing alcohol use and improving relationship satisfaction for both the patient and their partner. Shared activities and behavioral assignments are given to help increase positive feelings and communication between partners. Behavioral couples therapy has been shown to improve marital satisfaction, and improving relationship functioning is conducive to sobriety, therefore patients with motivated partners can benefit from this intervention. 216 Motivational enhancement therapy is a less intensive psychosocial intervention that utilizes motivational interviewing to elicit patient reactions to feedback, help patients commit to change and collaborate on a plan to change their behavior. It helps improve the patient’s awareness of their own ambivalence about changing their behaviors and enhances their self-efficacy. Patients are encouraged to involve a significant other in at least one session in order to improve outcomes. 216 Twelve-step facilitation therapy is utilized to help the patient become more actively involved in Alcoholics Anonymous (AA) or other 12-step programs. It involves 12 sessions of individual therapy, encouraging the use of AA and helping the patient understand the steps of the AA program.
Sessions are structured and are spent reviewing events of the past week related to recovery, introducing material related to the 12 steps, and creating a homework assignment and developing a plan for the next week’s recovery-related activities. Twelve-step facilitation therapy has consistently improved participation in 12-step programs and produced significant improvements in some drinking outcomes such as abstinence when compared to cognitive behavioral therapy or motivational enhancement therapy. 216 Addiction Conclusion Patients who suffer from substance use disorders have a number of hurdles to overcome in their road to recovery. Regardless of the severity of their condition, most patients will require customized treatment based on patient factors, preferences, and comorbid disease states. Many patients will require more than one attempt at quitting, and healthcare providers can offer guidance, motivation, and support throughout their journey.
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