Researchers Give Topiramate Edge in Alcoholism Treatment
Alcohol Use Disorder
For decades, the American Psychiatric Association, or APA—long known in the U.S. as the source for widely accepted definitions of substance-related problems—maintained separate criteria for diagnosing problems stemming from a physical reliance on alcohol intake (i.e., alcoholism) and problems stemming from clearly dysfunctional, non-dependent alcohol abuse. However, over a period of 20-plus years, researchers and practicing physicians gradually amassed evidence that showed that issues of alcoholism and alcohol abuse commonly overlap in the same person and can potentially produce indistinguishable symptoms. In late 2012, a committee within the APA decided that current scientific thinking no longer supports a firm distinction between alcohol abuse and alcoholism. This same committee voted to create alcohol use disorder, a combined diagnosis that includes symptoms of both alcohol-related problems. The larger body of the American Psychiatric Association approved these changes in May 2013, and doctors now use the alcohol use disorder diagnosis when assessing such problems in their patients.
The three medications approved for the treatment of alcohol use disorder’s alcoholism-related symptoms—disulfiram (Antabuse), acamprosate (Campral) and naltrexone (Vivitrol, ReVia)—all interfere with some aspect of the rewarding effects of alcohol intake. For example, disulfiram greatly intensifies such unpleasant drinking side effects as heart palpitations and nausea, while naltrexone blocks some of the chemical pathways that provide alcohol with access to the brain. Topiramate is an anticonvulsant medication that decreases seizure activity by slowing down excessive rates of nerve cell communication inside the brain. When given to a person affected by a physical reliance on alcohol consumption, it can reduce the severity of alcohol withdrawal, a mildly to severely disruptive syndrome that occurs when a brain accustomed to the presence of alcohol does not get as much of this substance as it has come to expect.
Is It Really Useful?
In the study published in Alcoholism: Clinical & Experimental Research, researchers from the Veterans Administration and Stanford University Medical School conducted an analysis of seven randomized controlled trials designed to gauge the effectiveness of topiramate as an alcohol use disorder treatment. Such trials are considered the highest quality studies produced by researchers in any medical field. All told, 1,125 people took part in the seven prior trials. Some of the participants received topiramate, while others received placebo medications that mimicked the appearance of topiramate. Measurement of the relative effectiveness of the medication included such things as the rate of alcohol abstinence and excessive drinking among topiramate recipients, the level of alcohol craving among topiramate recipients and levels of a key liver enzyme used by the body in alcohol processing.
After completing their analysis, the researchers concluded that topiramate has a “small to moderate” positive effect on an individual’s chance of achieving or maintaining abstinence and decreasing participation in excessive drinking, as well as a similar effect on levels of the key liver enzyme in question. They also concluded that use of the medication has a positive effect on alcohol craving levels, although the difference here does not quite reach statistical significance.
The study’s authors could find no important biases or mistakes in the work of the seven teams of researchers under consideration. In addition, they concluded that the results of the seven randomized controlled trials held true even when they employed a heightened level of scrutiny during their analysis. However, the authors also note that, given the number of medication recipients involved, they could not determine which factors might potentially increase or decrease topiramate’s effectiveness in alcohol-related treatment. Altogether, they believe that the medication may be more effective than either acamprosate or naltrexone, two treatments much more widely prescribed for people affected by alcohol use disorder. Still, they emphasize a need for further study of topiramate in order to determine which specific factors contribute to its best use.