What is the treatment approach for ethanol (ETOH) abuse using gabapentin and naltrexone?

From the Guidelines

For ETOH (alcohol) abuse treatment, a combination of gabapentin and naltrexone can be effective, but the most recent and highest quality study recommends considering pharmacological treatment, including naltrexone, acamprosate, and baclofen, for promoting the maintenance of alcohol consumption targets (abstinence or reduced consumption) in dependent patients 1.

Treatment Approach

When treating ETOH abuse with gabapentin and naltrexone, it's essential to consider the patient's overall health, including liver function, as naltrexone may not be suitable for patients with severe liver disease 1.

• Naltrexone should be started at 50mg once daily orally, with liver function tests monitored before and during treatment.
• Gabapentin is typically initiated at 300mg on day 1, increased to 300mg twice daily on day 2, and then to 300mg three times daily on day 3, with further adjustments based on response up to 1800mg daily divided into three doses.
• Before starting naltrexone, patients should be abstinent from alcohol for at least 3-4 days and not be using opioids, as naltrexone can precipitate withdrawal in opioid-dependent individuals.

Pharmacotherapy and Psychosocial Interventions

Gabapentin helps manage withdrawal symptoms and cravings by modulating GABA neurotransmission, while naltrexone blocks opioid receptors, reducing alcohol's pleasurable effects and cravings 1.

• This pharmacotherapy should be combined with psychosocial interventions such as counseling, support groups, or cognitive behavioral therapy for optimal outcomes.
• Treatment duration typically ranges from 3-12 months but may be extended based on individual needs and response.

Side Effects and Monitoring

Common side effects include nausea, headache, and dizziness for naltrexone, and somnolence, dizziness, and peripheral edema for gabapentin.

• Liver function tests should be monitored regularly in patients taking naltrexone, especially those with pre-existing liver disease.
• Patients should be closely monitored for signs of opioid withdrawal or other adverse reactions when starting naltrexone.

From the FDA Drug Label

To reduce the risk of precipitated withdrawal in patients dependent on opioids, or exacerbation of a preexisting subclinical withdrawal syndrome, opioid-dependent patients, including those being treated for alcohol dependence, should be opioid-free (including tramadol) before starting naltrexone hydrochloride treatment An opioid-free interval of a minimum of 7 to 10 days is recommended for patients previously dependent on short-acting opioids

The patient with ETOH abuse should be opioid-free for at least 7 to 10 days before starting treatment with naltrexone.

• Opioid-free interval: a minimum of 7 to 10 days is recommended for patients previously dependent on short-acting opioids.
• Gabapentin is not mentioned in the provided drug labels, therefore its use in conjunction with naltrexone for ETOH abuse treatment cannot be directly addressed based on the given information.
• Naltrexone dosage: a dose of 50 mg once daily is recommended for most patients with alcoholism 2. The treatment should be initiated with an initial dose of 25 mg of naltrexone hydrochloride. If no withdrawal signs occur, the patient may be started on 50 mg a day thereafter 2. It is crucial to ensure the patient is opioid-free before starting naltrexone hydrochloride treatment to avoid precipitated withdrawal 2 2.

From the Research

ETOH Abuse Treatment

• ETOH abuse treatment can involve the use of gabapentin and naltrexone, with studies indicating that gabapentin can be effective in reducing symptoms of alcohol withdrawal and cravings 3.
• However, there is concern about the potential for gabapentin abuse, and it should only be prescribed as a second-line alternative to standard therapies after screening for opioid or other prescription drug abuse 3.

Gabapentin and Naltrexone Combination

• The combination of gabapentin and naltrexone has been shown to be effective in improving drinking outcomes during the first 6 weeks after cessation of drinking, with the naltrexone-gabapentin group having a longer interval to heavy drinking and fewer heavy drinking days than the naltrexone-alone group 4.
• The addition of gabapentin to naltrexone has been found to improve drinking outcomes over naltrexone alone during the early drinking cessation phase, although this effect did not endure after gabapentin was discontinued 4.

Naltrexone and Behavioral Therapies

• Naltrexone has been shown to be effective when combined with cognitive behavioral therapy (CBT) for the treatment of alcohol dependence, with the CBT-naltrexone group doing better than other groups on a variety of outcome measures 5.
• CBT approaches have been found to have a high level of empirical support for the treatment of drug and alcohol use disorders, with a modest effect size and relatively durable effects 6.
• The combination of naltrexone and CBT has been found to be synergistic, with naltrexone increasing control over alcohol urges and improving cognitive resistance to thoughts about drinking 7.