National Post (National Edition)
Pills can help people control risky drinking
SO WHY AREN’T MORE DOCTORS PRESCRIBING THEM?
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 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, higher than the number for heart attacks. And the rates of harm are rising faster for women than for men.
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 oneyear 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 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.
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) 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.”
The best studies suggest the success rate of AA 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.”
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.
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.
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.”