When Will We Have a Cure for Alcoholism?
A wise man once said, that you can consider yourself lucky in life if the cognac you drink is older than the woman that you’re sleeping with. Where a man might not find himself so lucky is if he falls into the category of Alcohol Use Disorder (AUD) – or what we’re going to hereon refer to as alcoholism. Alcoholism is a global problem that has left no country unscathed. A global study found that more drinking and heavy drinking occurs among men, while more long-term abstention occurs among women. No cultural differences or historical changes have entirely erased these differences. Regardless of which gender is affected the most, alcoholism has a negative economic impact of around a quarter of a trillion dollars in the United States alone. What doesn’t help is the fact anyone over the age of 21 can buy alcohol on any street corner. In India, you don’t even need to leave your house:
The problem is much more widespread than you might think, because alcoholics are very good at keeping the problem hidden. We’ve all probably known a friend who we didn’t know was an alcoholic until they showed up one day sober. Alcoholics are everywhere, and we’ve even found them in dry countries – like the Maldives – where alcohol is illegal except at resorts. Still, you will find alcoholics in the capital city, Malé, who sustain their habit on the black market which manages to “skim” alcohol from the resorts. It’s an expensive habit though, and a small bottle of vodka will set you back twenty greenbacks.
Having observed the effects of alcoholism firsthand for a long time, we think that the biggest barrier preventing an alcoholic from getting sober is themselves. You have to want it bad enough to take advantage of available treatments otherwise you’re never going to get well. Since there is no known cure for alcoholism, the alcoholic needs to make some effort on their own to seek treatment – and adhere to the treatment plan – otherwise, nothing will change. As Albert Einstein once said, “the definition of insanity is doing the same thing over and over again, but expecting different results.”
While we’re probably all familiar with rehab programs, the Twelve Steps, and Alcoholics Anonymous, we’re more interested in looking at what drugs are available – or under development – that help cure alcoholism. We were surprised to find only three FDA-approved drugs for fighting alcoholism, but certainly not curing it. Let’s look at each active ingredient briefly, none of which we found overly compelling when it comes to serving as a “cure for alcoholism.”
First approved by the FDA in 1951, Disulfiram works by producing immediate and severe negative reactions to alcohol intake. It does not reduce alcohol cravings, so as you would expect it suffers from extremely poor compliance. One way to combat this is by administering the drug using implants under the skin so the drug can be continuously released over a period of up to 12 weeks. Some people think it’s the greatest thing since sliced bread and others don’t. These variations in results are not surprising considering that it’s largely a psychological deterrent that helps those who really want to quit. Generics can be purchased for under $1 a day.
First approved by the FDA in 1994, Naltrexone is an opioid receptor antagonist that is effective in “reducing relapse to heavy drinking.” According to AddictionCenter.com, “Naltrexone suppresses the euphoria and pleasurable sensations of alcohol. Alcoholics no longer receive a “reward” for drinking once they are on Naltrexone and are therefore less likely to continue consumption.” In 2006, the FDA approved an injectable, extended-release form of Naltrexone called Vivitrol which is injected once a month. It is not intended to help someone stop drinking, but rather it is administered to patients who have already detoxed and don’t want to relapse. While the oral form is cheap (about $1 a day), the injection is expensive (around $40 a day).
One way to measure a drug’s effectiveness is to look at something called Number Needed to Treat (NNT). This refers to the number of patients that need to be treated for one of them to benefit. According to a great presentation by Doctor Barbara Mason, Director of Alcohol at the Scripps Research Institute, for Acamprosate, you need to treat 8.6 patients before one sees a benefit. For our next drug, that number is only slightly better at 7.5 patients. (By the way, no NNT was given for Disulfiram.)
Approved by the FDA in 2004, Acamprosate is used for the maintenance of abstinence from alcohol in detoxified alcohol-dependent patients. Everything you ever wanted to know about this drug can be found in a paper titled Acamprosate: A prototypic neuromodulator in the treatment of alcohol dependence. The paper describes the drug as taking a neuromodulatory approach that “seeks to restore the disrupted changes in neurobiology resulting from chronic alcohol intake.” Here is an excerpt from that report which describes how this drug works compared to the two we previously talked about:
More specifically, earlier drugs such as disulfiram targeted alcohol metabolism and naltrexone acts as an antagonist on opioid receptors, whereas by its actions acamprosate works to ameliorate the underlying changes in neurochemistry caused by chronic alcohol intake and to restore homeostasis to those systems.
The report goes on to say that because of the drug’s excellent safety record, it is now the most widely prescribed drug therapy in the treatment of alcoholism. Costs for the drug sit at around $3 a day.
New Drugs to Combat Alcoholism
Alcohol misuse is the fifth leading risk factor for premature death and disability worldwide, so we were quite surprised to find that very little research is being done to formulate new drugs to combat alcoholism. In fact, using drugs to treat alcoholism is quite rare. As much as Americans love popping pills, fewer than 10% of afflicted Americans receive pharmacological treatment for alcohol use disorder. That’s according to a paper that suggests Gabapentin for the treatment of alcohol use disorder. Gabapentin is actually used to treat restless leg syndrome, one of those afflictions that almost just seems made up for the sole purpose of selling some drug to treat it.
The French health authorities recently approved a muscle relaxant to treat alcoholism called Baclofen, a medication that is presently used to treat spasticity. According to an article by The Fix, there are concerns about the side effects and “critics of using baclofen for alcoholism say that its efficacy has not been proven, while others say that treating addiction with another substance is a bad idea.”
Ibudilast, an anti-inflammatory drug, primarily used by asthmatics in Japan, showed promising results in getting rats to stop drinking. In February of last year, a paper was published titled “Development of the Neuroimmune Modulator Ibudilast for the Treatment of Alcoholism: A Randomized, Placebo-Controlled, Human Laboratory Trial.” As the paper’s title suggests, this was the first study that looked at how Ibudilast affects human alcoholics. In short, the findings can be summed up as follows:
These exploratory analyses, although interesting, should be considered with caution and future studies are needed to more clearly ascertain the biobehavioral mechanisms of action of IBUD for AUD as well as its clinical efficacy.
A Future Cure for Alcoholism
Alcoholism represents a large unmet medical need, and we’d like to hear more from any startup or company out there that’s working on a medical treatment. We’ve seen lots of apps and “digital treatment plans” but we’re largely interested in hearing about pharmaceutical approaches being taken to address the problem. If you happen to know of work that’s being done in this area, drop us a note in the comments section and we’ll update this article.
If you’re a freshly-minted MBA with visions of making the world a better place, go to one of the AI drug discovery companies and see if you can’t come up with some new drug formulation that helps cure alcoholism. Need funding? Try the Bill and Melissa Gates Foundation which is dedicated to “improving the quality of life for individuals.” Maybe they can help fund a drug that could improve the quality of life for the more than 15 million alcoholics in America. Alcoholism is the third leading preventable cause of death in the United States, and it’s kind of pathetic that we’re having to try and use a drug for treating “restless knee syndrome” to try and treat alcoholism because we’re so short on options at the moment.
Of the top New Year’s resolutions for 2019, third on the list was the desire by 15% of all Americans to drink less alcohol. That desire is more important than anything else. In the best-case scenario, we can hope for a drug that, when taken as prescribed, makes the person detest alcohol so much that they never want to drink another drop. Then we would want this drug to be something that is not easy to stop taking. Perhaps it could be implanted in much the same way contraceptives are, so that the alcoholic isn’t tempted to forgo medication on a bad day. The more difficult it is to “not adhere” and the longer it can take effect before needing to be administered again, the better. Unfortunately, there is no cure for alcoholism, and no miracle drug on the horizon. Not wanting to drink anymore is about the closest we’re going to get to when it comes to a finding a cure for alcoholism.
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