Podcast: Alcohol use disorder & anticraving medication
Transcript
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Dorian Deshauer: Roughly 20% of Canadians will meet criteria for alcohol use disorder at some point in their lives. Fewer than a third of those people will ever receive addiction treatment, and only a small group will receive medications meant to help reduce alcohol consumption. Roughly half a percent of Canadians with alcohol use disorder will end up using anticraving medications. Now, anticraving medications are in fact a good option for primary care physicians to keep in mind for patients with moderate to severe alcohol use disorder. I'm Dr. Dorian Deshaur, deputy editor for the Canadian Medical Association Journal. Today I'm talking to Dr. Jon Mong and Dr. Paxton Bach. They are joining me today to talk about anticraving medication for alcohol use disorder. They co-authored a practice article published in CMAJ, along with their colleague, Dr. Keith Ahamad. I've reached them in Vancouver and Ottawa. Welcome.
Jon Mong: Hi, there.
Paxton Bach: Thanks, Dorian.
Dorian Deshauer: So to begin with, can you tell us about yourselves?
Jon Mong: Yeah, absolutely. So first of all, thank you so much for having us on. It's it's really an exciting thing to be able to talk about. I'm Jon. I'm a general internist working at the Ottawa Hospital with a clinical focus in Addiction Medicine. I also work with the substance use program consult team, and I'm doing my Master's in quality improvement and patient safety to the University of Toronto's IHPME. I really became interested in Addiction Medicine, you know, during my training in internal medicine, because so often, we would see patients admitted to the CT (clinical teaching unit) with substance use issues. And while we could take care of their acute issue, whether it was osteomyelitis, or alcohol withdrawal, or alcohol induced pancreatitis, it often felt a bit like we were putting a bandaid on the solution and not really helping them with their underlying substance use issue. And that sort of led me to get interested into into this area of medicine. And I think it's been such a useful set of skills to have, and I'm really excited to be talking about it today.
Dorian Deshauer: Paxton?
Paxton Bach: Yeah. Thanks. Thanks, Dorian, and thanks very much for inviting us to be on the podcast today. My name is Paxton Bach. I'm a clinical assistant professor at the University of British Columbia here in Vancouver. And I'm a general internist and addiction physician working at St. Paul's Hospital in downtown Vancouver. I also, in addition to that, I'm the program director for the BC Center on Substance Use Clinical Addiction Medicine fellowship. And in that role, I get to work with a lot of trainees and teach about the principles of Addiction Medicine, which is an area that I am also very passionate about. I, like Jon, I'm a general internist and was really struck by my inability to help a lot of the patients on CTU (clinical teaching unit) with some of the underlying drivers of of many of the presentations. And that's what led me to explore this area of medicine. And I would just echo Jon it dovetails very well with my skill set as a general internist. And it's a really satisfying area of medicine to practice in, but also to teach in because I think it's underappreciated how much evidence and how many tools we do have to help people dealing with substance use disorders.
Dorian Deshauer: Thanks for that introduction, but actually, it does give me some context as to how you're seeing the world and sort of seeing the problem of alcohol use. It's actually quite far down its trajectory, by the time people are already affected in hospital. So Jon, can you talk to listeners who are working in primary care who might just want to know how do I know if the person in front of me has an alcohol use disorder?
Jon Mong: Absolutely. And I think that's an excellent question. You know, whenever I talk with trainees or even colleagues about what constitutes alcohol use disorder, you know, invariably someone asks, well, what about that time I got drunk and blacked out in undergrad does that mean I have an alcohol use disorder. And at the end of the day, it boils down to sure there are the diagnostic criteria in the DSM-5. But the way that, the thing that really separates an alcohol use disorder from using alcohol, more generally speaking, are something that we tend to think of as the four Cs. And those stands for cravings, compulsions, control and consequences. And so when you break it down, essentially, those are the features which will separate someone with any sort of substance use disorder, alcohol included, from again, someone who simply uses the substance. So breaking it down a bit more creating is essentially. So it's almost like a physical pang, like hunger, that someone has to use the substance. And compulsions are very like an overpowering urge to use that substance. Consequences, of course, or when someone continues to use a substance or has negative consequences as a result of their use. And control is when patients and people feel like they no longer have that ability to moderate or temper how much they use. And it's really those four Cs that I keep in mind when you know discussing alcohol use with patients and whether or not that you know, a patient's use pattern fits more into a disorder or simply just occasional regular use.
Dorian Deshauer: That's really helpful to moving beyond just a straight counting approach to alcohol intake. So you're wanting to look at the bigger picture and a person's life. Paxton, so can you help us understand them? I guess what we're talking about now is the conversion of evidence based medicine into practice. Because when we're talking about anticraving drugs, we're talking about people who have moderate to severe alcohol use disorder. How do you differentiate that group from people with a milder addiction, who might not necessarily benefit from the anticraving drugs.
Paxton Bach: I think you set up really nicely there that we do have criteria to make these designations through the DSM. But as you alluded to, you know, treating the patient in front of you is not necessarily that black and white. And I think that it's important, remember that people will fluctuate, but may potentially fluctuate along that spectrum at different points in their life as well. So what may, at one point meet criteria for severe alcohol use disorder may at another point, not not necessarily do so. So I think that for me, at least I move a little bit beyond the DSM criteria. At this point, I just have a conversation with the patient. And I think that the way that this was framed to me once by somebody I work with was really approaching these questions and these conversations with curiosity, because I think there remains a fair amount of stigma in Canada around people with substance use disorders, alcohol included. And so there can be some reticence I think, on the side of a patient to really open up and discuss their alcohol use. So approaching it with curiosity and a non judgmental way I think is is really an important theme that's going to translate through all the messages we talk about today. For me, the pieces that I really focus on that helped me make this distinction between mild to more moderate or severe alcohol use disorders, as well as to who might benefit from more intensive treatment with things like pharmacotherapy really comes down to, as Jon mentioned, those four Cs. In particular, on how much success they've had in the past, using other approaches to try to cut back. You know, many people may at some point in their life access some psychosocial supports for their alcohol use disorder, or maybe I've just tried to cut back on their own. And so that I think, is a really helpful question to frame where somebody is at, as well as the consequences they're experiencing. And somebody who's experiencing very significant health or social or financial consequences related to alcohol use, that's, I think, a real red flag, that they may be progressing further along that spectrum. But really, what it comes down to, I think, is is just making sure patients are aware of their options, and can kind of choose from a menu of things be that pharmacotherapy or psychosocial resources, to help them meet whatever their goals are at that moment in time.
Dorian Deshauer: So actually, that's really interesting. If we're talking about a spectrum, I'm imagining step therapy, I'm imagining that the anti-craving drugs are going to be further down that spectrum. But I guess before we start walking through the spectrum, my question would be would you ever start almost like the first thing you do introducing an anti-craving drug, say simultaneously with other interventions? Or would you always make that a stepped, a step conversation?
Jon Mong: You know, it's interesting that you bring up the idea of a sort of tier or step, you know, try the psychosocial interventions first before, you know, quote, unquote, progressing to pharmacotherapy. And I think that, again, because these medications haven't been so well used or well known, we tend to think of them as you know, the quote unquote, next step or the big guns, whereas really, they've got great evidence to be used in conjunction with or even solely, you know, as the first line therapy when it comes to things like naltrexone and acamprosate. And I think to reiterate, what Paxton was saying is that these are one of many tools that, you know, we as physicians have in our back pocket, when it comes to helping patients meet their goals. And so I think it's really being able to know what options are available, and to be able to have a conversation with each patient about what they want, what they think will work for them. And you know, what they eventually want to, you know, what their goals are, in terms of what treatment, they eventually start. You know, I think it would be entirely reasonable to offer a patient pharmacotherapy in conjunction with psychosocial interventions. It would be entirely reasonable for a patient to, you know, have that conversation about pharmacotherapy and decide that they don't want it initially. And it would be, again, entirely reasonable for a patient to say, you know, I only want naltrexone and I don't, you know, really want to join a group or go to therapy. And, you know, I think it's important that we have these options available, because without them, we're not doing the best thing that we can for our patients.
Dorian Deshauer: Actually, what I'm hearing reminds me a lot about psychiatric practice. And quite honestly, as a psychiatrist, I look very much to a person's personal preference, when we're talking about medications or a menu of of interventions. So I guess it doesn't, it's, it shouldn't be a surprise that we could think the same way about alcohol interventions. So along that conversation, have either of you figured out a good way to start that sensitive topic to start moving the conversation toward alcohol use in, say, in a primary care setting?
Paxton Bach: So I guess I should say for full disclosure, Dorian, that I am an addiction medicine specialist, I work primarily in an inpatient setting, or in a in a specialty clinic. So that's not an environment that I tend to operate in. But I, what I often talk about with with providers is two things. It's really about 1, I think, normalizing this conversation as a part of general primary care, I think we talked to people, people are generally fairly used to talking about things like smoking, I think at this point. And so just really normalizing this conversation is just just a part of a conversation about somebody's habits and lifestyle, and making a part of your routine care. One of the, one of the documents that we did that I will reference often, at least in my teaching, is that British Columbia Center on Substance Use Guidelines for the management of high risk drinking and alcohol use disorder, which is a, quite a lengthy guideline that came out just over a year ago now in BC, and really contains a lot of really helpful details in terms of how to manage these situations. I should also mention that it's it's currently being translated into a National Guideline, and that's a project that's underway. But one of the tools that it highlights as as worth incorporating into general primary care is screening for alcohol use disorder, and recommend screening annually just using something called the single alcohol screening question, which is simply asking somebody in the past year have you consumed more than three drinks for a woman and four drinks for man, which as you mentioned earlier, I think I shy away sometimes from being too linear in my thinking around how many drinks is okay or not okay. But it is a very helpful screening question, I think, to broach this subject and allow you to begin to explore it a little bit more, again, with curiosity, without judgment, just talking to somebody about their health in general and, and how alcohol fits into their life.
Dorian Deshauer: How do you tease out cravings in that conversation?
Paxton Bach: Yeah, I mean, I would start by simply asking something. I mean, I think many people do clearly identify their cravings as such. But if I can take a step back, I think that one of the really important questions that I find helpful in guiding treatment for any substance use disorder at all, is asking somebody why they use their substance of choice, just why and letting them go wherever they want to take that question. And it can be incredibly illuminating. Some people don't really know how to answer and they just don't, but they may just say that they do but a lot of people have a lot of insight in why they use and it may be that they clearly identify very significant cravings, or an inability to get drinking or other substances out of their mind, it may be very different, a lot of people will tell you they drink because of anxiety, or because it's part of their routine or out of boredom, you people will have many answers to that question that I think can really help guide the conversation further and really helped me as the clinician get a sense of what treatments I think may be worth exploring a little bit further with them, keeping kind of that, that "why" right at the front of the conversation.
Dorian Deshauer: I kind of like that approach. And, again, I'm gonna ask, if I could, about a little follow up here. So if you, if you're hearing from somebody that they're feeling bored, that they're drinking because of boredom, or that they're drinking because of anxiety, are there specifics that you're listening to, will help guide your choice to move toward anticraving medication?
Paxton Bach: That's a really excellent question, Dorian. And something that's actually, we talk about this a lot. Because I would like to think that that is true. I think that, you know, we conceptualize alcohol use disorder as one entity. But I think that that's not really, it's doing a disservice to our patients, it's, you know, it's a very heterogeneous condition, or disorder. And people do drink for very different reasons, with very different patterns at very different times in their life. So I often think about that heterogeneity, and whether we can gain a better understanding of what treatments might work for somebody based on those patterns. That being said, I don't think we really have the evidence yet to support that. So it's something that's certainly in my mind, but I tend to, and moving into a little bit about medication specifically, at this point, I do tend to try and stick with our first line medications for most patients as our first options, just because they are, that they do have the best evidence support and are best tolerated. And they tend to be more effective. So, well, I hope that we gain that ability to be granular in that sort of way at some point in the future. I'm not quite sure that we have the evidence to support that yet, at least.
Dorian Deshauer: So I'm hearing that there's quite a lot of non-specificity in both language that people use to describe their drinking, and also in the language that we use around medications. In other words, what type of language would get somebody to be on medications, would their language change as they start to describe that feeling when they're taking the medication.
Paxton Bach: Yeah, I would agree with that. I, you know, I think that everyone, everyone has unique experiences with alcohol or their substance of choice. And again, I am endlessly surprised by patients and what may work for one or or may not work for another. So I try not to come in with any preconceived notions. The nice thing about these medications, as we've mentioned in this article is they're they're generally quite well tolerated. And you can get a sense of their effectiveness quite quickly. So I work with patients to, when the decision is made, to try medication, I'll work with a patient. We'll pick one and start it and we'll go from there, and I'm happy to rotate through as many medications as needed in conjunction with other supports to find a combination that works.
Dorian Deshauer: Well, since we're talking about medications. Why don't we move on to the question of what anticraving medications are, and how they work physiologically?
Jon Mong: Yeah, absolutely. So you know, this is the part that sort of tickles my fancy as an internist, the pharmacology, and I just find it absolutely fascinating. So anticraving medications are a group of medications similar to how within antihypertensives you've got ACE inhibitors, beta blockers, and, and all that. So the two first line agents for alcohol use disorder and adequate medications are naltrexone and acamprosate. And naltrexone, you might say, hey, wait a second, that sounds a bit like naloxone, that's an opioid blocker, how does that work on alcohol use disorder? And you're right naltrexone is similar to naloxone in that it's an opioid blocker. And the way that it works very interestingly that it blocks the effect of endogenous opioids in our limbic system and our reward pathway. And in patients with alcohol use disorder, they have an outsized higher than normal response of opioid endogenous opioid release to using alcohol. And the thought is by providing naltrexone, you can block that reward pathway and so by the principles of operant conditioning, when patients with alcohol use disorder who are on naltrexone use alcohol, they don't get that same pleasurable effect. And so there's less of a drive or a desire to use alcohol, they can perceive the mechanism of action is less well known, but it's thought to modulate the GABA and NMDA receptors. And it can help to mitigate some of the sub acute withdrawal symptoms. So withdrawal symptoms that, you know, last maybe weeks, two months after cessation of alcohol. And again, just going back to that idea of, you know, no two patients are the same in alcohol use disorder, people will use alcohol for very different reasons. It's a very heterogeneous disorder. As it turns out, naltrexone is really quite good for patients who want to reduce their heavy drinking days. In fact, it has a number needed to treat of 12 to reduce heavy drinking days. But it's also pretty good for helping patients maintain cessation from alcohol. And it's got a number needed to treat of 20. Acamprosate is a bit different. It only helps for patients who wish to achieve cessation from alcohol, at which point it has a number needed to treat of 12. And, you know, as an internist, these numbers are ridiculous, like crazy, right? You know, I'm used to seeing NNTs of 30, 40, 50. So when I first learned about these meds, and you know, that they've got NNTs of 12 to 20. You know, it's it's almost criminal, how underutilized they are. And, you know, they they have very direct pharmacologic mechanisms of action, and they're evidence based and they work.
Dorian Deshauer: So okay, looking at the two, let's just start with naltrexone and acamprosate, and say, again, think you're in a primary care office, and you're having to think, okay, which one should I try? Which one should I prescribe first, which is safer? Are there anything special things I should know about one or the other? And prescribing?
Jon Mong: Yeah, absolutely. So I think it comes down to the individual patient, any specific coworker and medical conditions and what other medications they're on. So the first question I tend to ask myself is, what's the patient's goal. If the patient wishes to achieve alcohol cessation and maintain alcohol cessation, then I'd be leaning towards acamprosate as opposed to naltrexone simply because the evidence is better for maintaining cessation. That being said, there's a whole host of other factors. Acamprosate is dosed three times a day. And of course, you know, it's, it's tough to even remember to take a medication once a day, you know, just speaking from personal experience. So three times a day can be a bit tougher for patients to remember. Naltrexone, conversely, is once a day, and so it's just a bit easier for patients to remember to take. And it can just help if patients, you know, are out of the house quite a bit, or if they don't have a very regular schedule, then maybe naltrexone might be a better choice from a dosing perspective. In terms of contraindications, and side effects, they're a bit different as well. So naltrexone, again, going back to that idea that it works similarly to naloxone, if patients are on opioids or you know, and that includes opioid agonist therapy like methadone or suboxone, then naltrexone is contraindicated because it will inhibit or stop the opioids from working. So if someone is also prescribed opioids of any kind, then naltrexone is out the window unfortunately. And naltrexone is also contraindicated if there's severe hepatitis or liver disease. There's no hard and fast cutoff, but, you know, probably a MELD of 15. So end-stage liver disease, you know, you don't want to be using naltrexone in that case, or if they have ASD or ALT [enzymes] more than two times the upper limit of normal. So those are also contraindications to naltrexone. In comparison, acamprosate can be used even in in liver failure, but it's contraindicated when the creatinine clearance is lower, and you just have those two just in case the creatinine clearance is less than 50. And you can't use it if the creatinine clearance is less than 50. As Paxton was saying earlier, both meds are pretty well tolerated. Side effects tend to be pretty transients for naltrexone, some fatigue, sometimes a bit of GI upset, but again, quite transiently, and very well tolerated. And similarly for acamprosate. The major side effect is GI upset, but again, transient and very well tolerated. And so you know the magnitude of the potential benefits, I think, really quite strongly outweighs any, you know, minimal side effects that might arise.
Dorian Deshauer: Now, can I ask you about availability? And I recall not long ago, there was a shortage in Canada of acamprosate. Is that still happening now or like in other words, we're talking about acamprosate but can people actually get it in Canada right now?
Jon Mong: Thankfully, yes. I believe the shortage ended in July of last year. But you're right, there was a shortage for a while with acamprosate. But as of right now, both medications are available, and I believe covered under most provincial programs. I believe so in Ontario, they are certainly covered under the ru code. I wouldn't know for sure about the other provinces.
Dorian Deshauer: Paxton any full coverage in British Columbia?
Paxton Bach: They are covered. They're covered in British Columbia under something called collaborative prescriber agreements. So yes, both of those are also available in our province.
Dorian Deshauer: And we've talked a little bit about starting the medications, introduced the two the best known ones, naltrexone and acamprosate. In your article, you mentioned topiramate and gabapentin, which we don't have time really to go into here. And I think people are more interested can look at your article and and further readings. But I want to ask you both actually, about the flip side to starting a medication and that is, how do you know it's time to stop a medication?
Paxton Bach: That's another excellent question Dorian and obviously one of the first questions that comes up from patients when we are initiating these medications. I typically suggest, you know, starting with these medications, and as I mentioned earlier, quite quickly, you should be able to establish whether they're achieving any benefit or or not from medication. So usually I'll try and see them back in one to two weeks. And but if by a month into a good trial of medication, they're not seeing any benefit, I would be looking at alternative options, if they are seeing a benefit that becomes the question in terms of how long do we carry on down this road. And it it really varies, and I tried to put it as much as possible to the patient, generally, you know, 12 weeks is most typical duration that these medications are studied. So we tend to not have a great deal of data beyond that point in time. So I usually recommend that we try medication for a minimum of three months, if they're achieving some benefit. And then we sit down and we reassess. And if somebody feels if they're really obtaining a lot of benefit, and it's really helpful, and they're meeting their goals, and they're feeling good. And they want to carry on, that's fine, then we can carry it on, as Jon mentioned, they're very well tolerated medications. And I'm happy to keep going with them for as long as they feel they're there, helping them. Similarly, if somebody at three months, decides that they'd like to stop and kind of see how things go, I'm supportive of that as well. And we'll take it a day at a time and see how things go. And if they do stop and they find that cravings come back, well, then I'm more than happy to restart the medications and carry on for a period of time beyond that. But that's usually my suggestion is and it's within our BC guidelines, as well as three to six months as our initial trial. And then from there, you can reassess and make that decision collaboratively with your patient.
Dorian Deshauer: And just out of curiosity, a lot of psychiatric drugs, as you know, have withdrawal and rebound symptoms if you stop them all of a sudden, especially if you've been taking, you know, antidepressants for a while. Has anything like that been described with the anticraving drugs?
Paxton Bach: No, one of the one of the fortunate things about these medications is that really, there's not. Starting and stopping them is quite straightforward, at least with these first line medications, naltrexone and acamprosate. So it's not something we have to worry about as much with these medications, which is, again, why they're such helpful tools and really quite easy to incorporate into your practice.
Dorian Deshauer: That kind of leads me to the next question. I know that Jon has expressed very strongly his sense that the anticraving drugs are underused in medical practice. And so I wonder if we could put this sort of final section of our discussion around how anticraving medications have been received, both by medical experts and by consumers.
Jon Mong: I think there has been quite a bit of interest from both sides about, you know, these anticraving medications, which again, it's not to say that they're a magic bullet or a panacea to help patients with alcohol use disorder, but they are a valuable tool in our toolbox and, you know, anytime that there's something that could potentially, like all patients, I think it's and especially because there is robust evidence that they help, you know, I think there's going to be interest certainly, you know, locally within the Ottawa Hospital. You know, initiatives to improve their use have been very warmly received. And, you know, a lot of patients are interested in it because, you know, some patients aren't necessarily interested in the psychosocial nonpharmacologic interventions, and some are interested in a medication that will help them. And of course, some aren't, and then that's totally valid as well. But, you know, again, I think there's been a lot of interest in these medications and their use I think should be increased. Our knowledge and how to use them should be more widely disseminated.
Paxton Bach: And I would just echo that, I think, from a patient perspective, people are just really happy to have, to be provided with options, especially ones that they may not have tried to access in the past for people who this is not their first attempt at this. And I think from a provider perspective, you know, I think that's a medicine, in general, we tend to shy away from questions or conditions where we don't feel as if we are very well equipped to deal with them. I think that, you know, it's pretty natural instinct for clinicians in any specialty to gravitate towards problems that they feel that they can address. And so providing providers with tools in their toolkit, as Jon mentioned, giving people options that they can employ when they run into these situations. I think that it's really, really reaffirming and really helps encourage providers to ask these questions and kind of go down this path with patients. It's much more satisfying to have these conversations when you feel as if you are equipped to provide them with some help or some answers. And so I think that the feedback that I get is almost universally positive from both patients and providers alike.
Dorian Deshauer: Thank you for joining me today.
Jon Mong: Thank you very much for having us. It was a pleasure.
Paxton Bach: Yes, thank you for having us. And thank you for bringing us on the show to talk about something that, that obviously we feel pretty strongly about. It was a pleasure to share the conversation with you.
Dorian Deshauer: I've been speaking with Dr. Jon Mong and Dr. Paxton Bach. Dr. Mong is a general internist working at the Ottawa Hospital with a clinical focus in addiction medicine. Dr. Bach is a clinical assistant professor of the Department of Medicine at UBC, and a general internist and addiction specialist at St. Paul's Hospital in Vancouver, BC. To read the article they co-authored along with Dr. Keith Ahamad, visit cmaj.ca. Also, don't forget to subscribe to CMAJ Podcasts on SoundCloud, or podcast app and let us know how we're doing by leaving a rating. I'm Dr. Dorian Deshauer, deputy editor for CMAJ. Thank you for listening.