Can This Pill Stop You From Hitting The Bottle?

Addicts know the pattern all too well--that roller-coaster ride of intoxicating highs and wasted lows. David Nott's journey has been one of the worst. At 28 he was a successful underwriter for Lloyds Insurance in London with a Porsche, a Ferrari and a country manor. But after two decades, Nott's life had spiraled into a mess. His addiction drowned his fortune, ruined three marriages and propelled him toward suicide. Drug of choice: alcohol. Breakfast was cheap Spanish wine; then came the vodka--a sickening cycle of passing out and coming to. He craved both another drink and a better life. "Once I was holding a glass of vodka and shaking and crying," says Nott, now 48. "I didn't want to drink it, but I couldn't stop."

It's a battle far too many are losing. Alcohol abuse costs this country a staggering $185 billion a year in everything from lost workdays to drunken-driving accidents--more than all illegal drugs combined. Six million Americans persistently misuse alcohol, and 8 million more are addicted; 100,000 will die this year from alcohol-related causes. Hospital charts are littered with the complications of chronic heavy drinking--heart disease, stroke, liver failure. Those who are still fighting spend years in and out of treatment, unable to kill the cravings that wreck their lives and, too often, the lives of those close to them. Fixing the problem is a herculean task. Alcohol courses freely through American society, from college bars to corporate lunches. There's no government booze czar, no war declared; nor has alcohol been banished to the sidewalks like cigarettes. Every year, alcohol advertisers spend more than $1 billion to promote the tasty, relaxing side of liquor--more than three times the annual budget of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Many addicts, meanwhile, are not getting the help they need.

But they may have reason to hope. Medications that act on the brain to help control the urge to drink are forging a new direction in alcohol treatment. Acamprosate, a pill used for years in Europe, will soon be under review by the FDA and could be available by prescription by the end of this year. David Nott took the drug in combination with counseling and has now been sober for three years. Without it, he says, "I'd be dead now." Next month the NIAAA will launch a major nationwide trial to test counseling together with a one-two punch of acamprosate and naltrexone, an anti-craving pill approved in 1994. The drugs "herald a whole new era in the treatment of alcoholism," says the NIAAA's Dr. Enoch Gordis. "The medications five to 10 years from now will be even better."

That might seem like cause for celebration--but reaction to the idea of treating alcoholism with drugs is decidedly mixed. Many recovering alcoholics, who beat their addiction with steely willpower and support groups, are leery: there are no shortcuts, they say, to staying dry. Gordy Brown, a recovering alcoholic in St. Paul, Minn., fears that addicts might be tempted by what they think will be an "easier, softer" way out of addiction--then shirk the hard work of dealing with the personal turmoil that may have led them to booze in the first place. "A pill," he says, "is about the bottom when it comes to taking responsibility."

Medication also has a tortured history in addiction treatment. Antabuse, the first anti-alcohol drug, in use since 1948, blocks the body's ability to absorb alcohol. Taking it, then drinking, provokes a violent response: headache, palpitations, vomiting. Some alcoholics swear by it, but many others can't stomach the effects. Other drugs, like the habit-forming sedatives Librium and Valium, make alcoholics even warier. They're still used to help calm the tremors and anxiety during the acute phase of detox, but they haven't completely shaken the bad rap they got decades ago when given long-term to help people stay calm after withdrawal. Kellie Baker was prescribed the sedative Xanax during rehab at the age of 16, four years after she started drinking heavily. "It was kind of a joke," says Baker, 31. "I'm trying to get sober, and here I was getting completely stoned."

But acamprosate and naltrexone are in a different class--they're nonaddictive. And even their proponents are not pushing them as a cure: their effects are moderate, and they're intended for use only in combination with counseling or support. They help ward off relapse, not get active drinkers to quit. And alcoholics must be highly motivated to cork the bottle, or the pills will have little impact. The first time Pierre Galard, a Paris artist, took acamprosate, it didn't reduce his desire for booze at all. "I wasn't ready to quit," he says. What the drugs do provide, scientists say, is a new option for those who've failed traditional therapy. Only 10 percent of problem drinkers get the help they need. Of those who go into patient rehab, about half relapse within the first three months of treatment. And self-help groups like Alcoholics Anonymous don't work for everyone. "Alcoholics are not all the same," says Dr. Bankole Johnson of the University of Texas Health Science Center at San Antonio. "The hope for the future is that we give people the treatment that is best for them."

The best treatment will depend, at least in part, on which of two broad camps drinkers fall into. "Alcohol abusers" drink persistently, despite causing chronic problems in their lives, jeopardizing relationships and jobs. They are not, however, physically addicted to alcohol, and some may be able to drink in moderation. But the "dependents" --for whom the drugs are intended--are a different story. They can't keep themselves from drinking, and many suffer the wrenching physical symptoms of withdrawal--nausea, tremors, hallucinations. For them, most experts agree, abstinence is the only way to go. "The normal drinker gets relaxed, gets woozy, and then something inside clicks on that says, 'You need to stop now'," says Kathy Olund, 58, a recovering alcoholic and vice president of the visitors' bureau in Flint, Mich. "I never stopped. I drank until I was drunk, and then I began drinking every day."

Why was Olund hammered with cravings for more, while most of us can tough out the hangover with a couple of aspirin? Environmental triggers, like an unstable home, and perhaps even certain personality traits like impulsiveness, may put people at greater risk. So do certain genes--probably a whole bunch of them. Adopted boys are two or three times more likely to become alcoholics if a biological parent is--even if they're raised by nonalcoholics. Researchers recently identified "hot spots," or regions of chromosomes, linked to a risk for alcoholism. Now they're zeroing in on the actual genes, hoping those genes will be new targets for designer drugs that will one day strike at addiction with precision.

Acamprosate is nowhere near that sophisticated. No one knows precisely how it works, but the drug (marketed in Europe by Lipha Pharmaceuticals under the brand name Campral) seems to quiet the glutamate system--brain chemicals that get stuck in a hyperactive state after alcohol withdrawal. As a result, some alcoholics say, acamprosate wards off the temptation to order a vodka when they smell cigarette smoke or go to a party--typical drinking "cues." In European trials, patients taking acamprosate--two pills three times a day--stayed off alcohol 10 to 25 percent more days than patients on a placebo. Overall, the drug nearly doubled abstinence rates (from 28 percent on placebo to 55 percent on acamprosate) over three months of treatment, says Dr. Barbara Mason of the University of Miami School of Medicine, a Lipha consultant and lead investigator of a U.S. trial of 601 alcoholics. The effects are not magic, but "we're really starting to make some inroads," she says.

For alcoholics in the United States, the closest thing on the market to acamprosate is naltrexone, originally approved to treat heroin addiction. The drug's effectiveness has varied in studies. In one dramatic finding in a small group of alcoholics, 95 percent of those who "slipped" and took a drink while on placebo went on to binge, but only 50 percent of patients on naltrexone did. If a medicine could similarly decrease the odds of moving from angina to a heart attack, says Dr. Ted Parran, an addiction specialist at University Hospitals of Cleveland and Case Western Reserve University, "every cardiologist on the planet would be lobbying for it to be put in the public drinking water."

Other drugs are on the horizon. A naltrexone cousin called nalmefene is being studied in the United States. An injectable form of naltrexone, given just once a month, is being tested to help improve compliance--a critical challenge in the future of drug treatment. Antidepressants like Zoloft and Prozac are being studied in depressed alcoholics. Drug combinations, like the upcoming trial of naltrexone and acamprosate, could hold the most promise, allowing medications to fire at different parts of the brain's wiring at the same time.

The greatest upside of the new science may be a wider acceptance of medication as a legitimate part of treatment. AA has no official policy on drugs, but a survey of 277 members in Buffalo, N.Y., found that more than half think a nonaddictive medicine that reduces the urge to drink either is a good idea or might be helpful. Only 12 percent said they'd advise someone to stop taking such a drug. And at Hazelden, the treatment center that is home of the famed "Minnesota Model" of counseling in combination with a 12-step approach, researchers are designing studies of both naltrexone and acamprosate. The pills, says research director Pat Owen, are not viewed as a threat to talk therapy, but they do raise new questions about the best approach to treatment: "People here are curious about the drugs. What will they do? What role will they play?"

Those questions point to the enormous challenges treatment providers still face. No matter how well a pill works on the brain, it will never be able to fix complex life issues. And people who abuse alcohol often suffer coexisting illnesses like anxiety, depression and schizophrenia; many abuse illegal drugs as well. How will one drug work when a patient is addicted to two? Simply understanding that alcoholism can be a tangle of conditions is leading to a more sophisticated concept of the disease. That could help refine the public's attitude. Now, says Parran, "a lot of people still believe that the alcoholic is nothing more than a slob, a spineless, weak-willed drunk." Researchers liken alcoholism today to depression 20 years ago, before drugs like Prozac helped it be seen as a biologically based, treatable illness. "As the science marches on and treatments become better, I think you will find that the stigma will lessen," says the NIAAA's Gordis. "It's a very exciting time."

It's certainly exciting for those who have managed to win the battle. Rebecca Tucker, 23 (high-school nickname: Champagne Becky), relied on rehab and counseling to quit three years ago. "I am pro-anything that helps someone get and stay sober," she says. "Twelve-step programs, drugs, counseling--anything that can make that hellish period of early sobriety the slightest bit easier is OK by me." Straight-up wisdom for the millions of alcoholics still fighting the demon.