Which medications can help with alcohol use disorder besides naltrexone?
In November 2021, I spoke with Dr. Roland Engelbrecht, a physician in British Columbia who works with the Canadian Alcohol Use Disorder Society. The society had been in the news after the death of its founder, and I wanted to learn how doctors there use medication for alcohol use disorder. We talked about the Sinclair Method, the other medications he reaches for, and why connection matters as much as any prescription.
This is an archive episode, recorded when the show covered addiction and recovery broadly.
How did the Canadian Alcohol Use Disorder Society begin?
At 0:52, Dr. Engelbrecht explained that the society grew out of a physician quality improvement project started by its founder. The founder had seen how rarely doctors prescribed medication for alcohol use disorder. Most patients were simply sent for detox and counseling instead.
So, the founder and his colleagues took an educational series to physician groups, hospitals, and clinics, sharing what the medications can do along with responses from patients. Unfortunately, in Dr. Engelbrecht’s view, these medications are still not used very much. The society’s aim is to reach as many prescribers as possible and help them feel comfortable prescribing the medications alongside psychotherapy.
Does taking naltrexone mean stopping drinking all at once?
At 2:37, I brought up the Sinclair Method, which the actress Claudia Christian has worked for years to promote. A person takes naltrexone while still drinking, which I described as a form of harm reduction, because not everybody is ready to stop drinking right away.
Dr. Engelbrecht called it a great use of the medication. At 3:16, he said medication offers an approach that is not all or nothing. Many of his patients cut down over time, some choose to stop completely, and others still drink, but far less than they did before.
At 4:04, I added that there is more than one way to use it. Some people take it every day, some take it in response to cravings, and some follow a schedule of several days a week, taking the naltrexone and having their drink an hour later.
What if the Sinclair Method does not work well enough?
People in online discussion groups often ask about alternatives when the method does not work as well for them. At 5:21, Dr. Engelbrecht said that in British Columbia the first choices are naltrexone and acamprosate (Campral). Acamprosate suits a person whose goal is to remain abstinent. It helps with cravings, but it is not really effective while the person is still drinking.
In fact, at 10:19 he advised at least three days without alcohol before starting it. He explained at 10:37 that he thinks of the two medications differently. Naltrexone fits someone who wants to cut down and perhaps stop later, while acamprosate fits someone whose goal is complete abstinence and who needs some help getting there.
He also described topiramate, which he said can be started while a person is still drinking, and several other options.
Can these medications be combined?
At 11:23, Dr. Engelbrecht said he sometimes uses topiramate together with naltrexone and has found the pairing very useful for a few patients. If a person later decides to stop drinking completely, he might wean them off one of the two, depending on which they found most effective.
Are benzodiazepines ever part of the plan?
At 13:10, I asked whether benzodiazepines are ever used as a form of harm reduction for a person with alcohol use disorder who also has anxiety. People have called them alcohol in a pill. Dr. Engelbrecht was clear at 13:42. He would not use them while someone is still drinking, and he would use them only for withdrawal management, not as a treatment. That is a narrow role.
What about someone who also takes opioids?
At 24:10, I raised a harder case. A person taking opioids for chronic pain cannot take naltrexone, because it would interfere with their opioid treatment. Of course, drinking while taking them is not a good combination either.
At 25:26, Dr. Engelbrecht said it depends on the patient’s goals. For someone taking opioids for pain, he said topiramate could be useful. For someone with opioid use disorder, he would consider starting buprenorphine, which, to oversimplify in his words, can act somewhat like naltrexone in the system and also help with cravings for alcohol.
Is recovery mostly about the substance?
At 16:18, I mentioned Stephen Finlay, an earlier guest from British Columbia who oversees a supervised consumption site in Surrey. In his work, making a connection with people, knowing their names, and building a relationship is an important part of helping them recover.
At 17:05, Dr. Engelbrecht agreed. In his experience, practicing addiction medicine turns out to be very little about the substance. It is about creating connection, helping people reconnect, and improving how they function. Over time, he said, the substance use tends to decrease on its own.
What kind of support helps alongside medication?
At 17:30, I mentioned Harry Derbitsky, another guest from British Columbia, who uses the Three Principles, and I asked what groups people can join to build a network of support. Dr. Engelbrecht did not point to one kind. At 18:06, he named Alcoholics Anonymous (AA), SMART Recovery, and the many groups that meet online.
However, his main advice was broader. He believes medication can help on its own but works better combined with psychotherapy, along with basic lifestyle changes and attention to general health. At 20:22, he added that every patient is unique. Some people need to cut down more slowly while they work on trauma and mental health.
Why do doctors need to know about all these options?
At 15:18, I said the conversation was getting technical, yet patients talk about these medications all the time, so the real task is getting doctors willing to look into them. Dr. Engelbrecht agreed at 15:45, adding that patients do their own research because they do not always get the answers they need.
At 19:14, he described the society’s next steps, slowed by COVID. The plan is to offer online workshops and educational material, and to help emergency department physicians start the conversation about these medications. Interestingly, he explained that many patients have no family doctor, so the emergency department is their only contact with the health care system.
Who is Dr. Roland Engelbrecht?
Dr. Roland Engelbrecht is a physician in Williams Lake, a rural town in British Columbia, and works with the Canadian Alcohol Use Disorder Society. He used to practice general family medicine but stepped away as his addiction medicine practice grew, and he now mostly sees people with opioid use disorder and alcohol use disorder. The society’s website, cauds.org, offers information on alcohol use disorder and its treatment that patients can take to their own physicians.
What can listeners take away from this conversation?
Naltrexone is not the only medication for alcohol use disorder, and a person who does not respond well to one approach may do better with another or with a combination. Yet, in Dr. Engelbrecht’s view, medication works best as part of a broader plan that includes psychotherapy, healthier routines, and real connection with the people who help.
How do I approach this today?
My thinking has kept developing since this conversation was recorded. Today my practice is built on one idea that runs through all of it: when the body has adapted to a substance, the safest way off is usually gradual, with the smallest steps the person’s nervous system can tolerate. Physical dependence is not addiction.
For alcohol dependence I use the Sinclair Method. The person takes naltrexone about an hour before drinking, and over time the drinking itself becomes less rewarding, so the urge fades gradually instead of being fought every day. It does not require stopping on day one, and it does not rely on willpower or meetings.
Like a slow taper, it lets the brain change at its own pace. For many people that makes it a more humane path than a sudden stop, which can also be medically dangerous for someone whose body depends on alcohol.
Call 911 or go to an emergency department if there is a seizure, confusion or hallucinations, or thoughts of self-harm. For thoughts of suicide or any mental health crisis, you can also call or text the 988 Suicide and Crisis Lifeline.
This page is educational. It is not medical advice, and listening to the episode or reading this page does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
Full transcript
A note from Dr. Leeds: my guests speak from their own experience and expertise, and the terminology they use is their own. Whatever the topic, this show holds to one distinction: physical dependence on a prescribed medication is not addiction. This transcript is educational content, not medical advice, and nothing here creates a doctor-patient relationship.
Read the full transcript (30 minutes)
Dr. Mark Leeds [00:00] Dr. Engelbrecht, welcome to the podcast.
Dr. Roland Engelbrecht [00:02] No, thank you for having me. Appreciate it.
Dr. Mark Leeds [00:06] Yeah, really excited to talk to you because, you know, the story came up in the news feed and my condolences for Dr. Harries, you know, the founder of the society. It was sad news, but it was good in the way that it brought attention to your organization and that there are other treatments for alcohol use disorder. The Canadian Alcohol Use Disorder Society. So yeah, I’m really interested, you know, because it’s, you know, here, you know, we’re aware of that there are some medical treatments for alcohol, and that some of these medications might be effective, but I didn’t realize that they might actually in some areas be in common use. So yeah, if you don’t mind, if you could tell us a little bit about the Canadian Alcohol Use Disorder Society and, you know, what the society does.
Dr. Roland Engelbrecht [00:52] Yeah, thank you. So the Canadian Alcohol Use Disorder Society actually grew out of a project that Dr. Jeff Harry started. He saw the lack in practice for treating patients with alcohol use disorder with medications. Most people either sent patients for detox and counseling or residential treatment centers, but pharmacotherapy wasn’t used very much. Still actually, unfortunately, isn’t used that much, and that’s what Dr. Harry’s tried to improve and change. So he started a project physician quality improvement initiative in his area and did an educational series. We went around to physician groups, hospitals, clinics, and gave a presentation on available medications to help treat alcohol use disorder. And along with that, he had some personal patient anecdotes that he shared and responses from patients just to actually show people that this treatment works. And out of that grew the Canadian Alcohol Use Disorder Society. Now, unfortunately, like you mentioned, Dr. Harry’s passed away, but the society still goes on. And our aim and goal is to reach as much prescribers as possible with this information and help them become more comfortable with prescribing these medications in combination with psychotherapy.
Dr. Mark Leeds [02:37] Okay, great, great. And now there’s one medication which is becoming a little kind of well-known here in the United States. Not really well known, but there’s, and I’m sure you’re aware of it, that the actress Claudia Christian for the last eight years has done a lot of work in trying to promote the use of naltrexone as a form of medication-assisted treatment for alcohol use disorder. But what she’s promoting is what they call the Sinclair method, where a person takes naltrexone while they’re still drinking, which I see as a form of harm reduction, you know, because not everybody’s ready to stop drinking right away. How do you and the society see that use of naltrexone?
Dr. Roland Engelbrecht [03:16] No, I mean, that’s definitely, it’s a great use of the medication. It’s, and that, I think that’s a big thing with medications is that it’s a new approach. So it’s not, it’s not an all or nothing approach. It’s not, you have to abstain completely. A lot of patients actually, when they get started on one of the medications, they will wean down over time. So it is more a harm reduction approach. And then some of them choose to stop drinking completely. And some people may still drink, but far less than they did in the past. And I mean, the Sinclair method is another great way of utilizing these medications. Instead of using naltrexone daily, you use it on an as needed basis.
Dr. Mark Leeds [04:04] Yeah. And that’s something that, you know, that doctors who learn about this Sinclair method, they should be aware of it doesn’t have to, there’s not just one way to do it’s that, you know, like I’ve discussed with some other guests in the podcast that it, some people may do well taking it every single day. Some people may take it in response to cravings before they have the medication and a drink. And then some people may even do it on a regular schedule of several days a week. They take their naltrexone and then their one drink an hour later. You know, there’s all different ways to implement the program. Now, one thing that’s interesting, because I’ve been following lately a lot of the discussion groups online, like on Facebook, there’s some groups where people talk about how the Sinclair Method is working for them. And one thing that comes up all the time is, you know, it doesn’t work as well for some people as others and there’s probably very likely some people that it won’t work for at all and people ask all the time what are the alternatives and some things that come up, for example, there’s nalmefene which is, I guess, a similar medication naltrexone that’s available in Europe and then there’s also medications that I think that Dr. Harris has lectured about, Campral which is a acamprosate I think what were the other ones gabapentin topiramate could you discuss some of those other medications a little bit
Dr. Roland Engelbrecht [05:21] Yeah so in british columbia at the moment we our first line choices are like you said naltrexone and then acamprosate acamprosate is more someone has a goal of remaining abstinent it helps with their cravings it’s not really effective if you take at wine you’re still drinking because of that it’s a sometimes a bit of a barrier to start someone on it but in individuals who are able to abstain for a few days and then start it can be quite useful so if it aligns with their end goal other medication as you mentioned is topiramate. So, topiramate also helps with cravings and can help reduce drinking over time. It can be started while someone is still drinking. And then we have gabapentin that can be used on its own or often as an add-on second-line treatment. And typical dosing is between 300 to 600 milligrams TID. Then there are two other medications, not on-label use in Canada at the moment, but there are some US studies showing benefits, and that would be Baclofen and Ondansetron, which is quite interesting. I find ondansetron very interesting because you’re using it at such a low dose and it’s really in a specific patient group so people with early onset alcohol use disorder that you would use it and even though it’s not on label and bc some of us do prescribe it and we’ve seen quite dramatic changes which is very interesting prescribing it because you typically go down to try to prescribe for nausea. And now we’re prescribing to a alcohol use disorder at such a low dose, and it still seems to help.
Dr. Mark Leeds [07:27] Yeah, that one is interesting. And I’d read about, I guess there’s a doctor who’s doing studies to see if they can use it as a genetically targeted treatment, that people that have a certain kind of a serotonin transport enzyme or something like that, or protein, that those people might respond better to it than other people. And someone had mentioned to me, I don’t know if this is true, that there might be 10% of people that try the Sinclair method with naltrexone and they won’t respond to that. So, you know, and someone had brought up, and I don’t, this is also, I’m not sure if it’s real or not, but someone actually on Twitter had said that there might, that there are people who are, whose addiction might be serotonin based and others who are, what was the other neurotransmitter they mentioned? And, you know, I had my notes here. It was, where did I have that? Yeah, serotonin or dopamine-based alcohol addiction. I don’t know if there’s any truth to that. I know, you know, but I was thinking like, is it, do we really need genetic testing or could we try, you know, one or both of these things, you know, going along, you know, and also with the, you know, ondansetron, that, you know, […] And, you know, do you have to use a lower dose or could someone use like the regular dose of it? Because it, you know, apparently is, you know, pretty safe medication. I mean, how would a doctor go about, you know, prescribing that and how would they decide to prescribe it for a patient?
Dr. Roland Engelbrecht [09:01] Yeah, so ondansetron, the typical dosing is about four micrograms per kilogram. So that’s quite low and you give that twice a day, which sometimes makes it quite tricky because you often can’t use the tablets to treat people with that because the tablets are much too big and if you break them down, it just crumbles. So what we typically say to patients, we use the pediatric suspension formulation, and that’s how you get to a low dose, because the doses are often around 0.2 milligrams BID. So very low.
Dr. Mark Leeds [09:40] Oh, okay. Okay, so that’s, and is that something that could be used in combination with the other medications, like, for example, with naltrexone? And as far as that’s that’s an important issue as far as say that someone is doing the Sinclair method and they might be drinking maybe even every night or a few nights, a few few nights a week or maybe even rarely, maybe like once a month or very rarely they take their naltrexone and have their one drink. Now, you had mentioned acamprosate, which is Campral that now is there a risk to taking that if someone is still drinking or is it just not helpful if they’re still drinking?
Dr. Roland Engelbrecht [10:19] It’s just not helpful. Yeah, that’s what the studies are showing. It’s just not helpful. So the advice would be at least three days abstinent before starting Campral.
Dr. Mark Leeds [10:29] Okay. Okay. And that’s, from what I’ve heard, that is safe to take with naltrexone, that those two can be prescribed together?
Dr. Roland Engelbrecht [10:37] Yeah. Yeah. I believe they can be prescribed together, but I don’t often use naltrexone and acamprosate in combination. Just, just feels like, well, the way I think about it is naltrexone, I would often prescribe if someone wants to cut down on their drinking and potentially stop, whereas Campral is more if someone wants to be, their goal is to be completely abstinent, but they need some assistance with that.
Dr. Mark Leeds [11:06] Okay. And then the topiramate, you said that, and that one, that’s like an anti-seizure, anticonvulsant, I think. Sorry about that. Topiramate, that’s an anti-seizure medication and that can be used while a person is still drinking?
Dr. Roland Engelbrecht [11:23] Yeah, it can. And I would sometimes use topiramate in combination with naltrexone. I’ve used that on a few patients in the past and found it very useful. And if the individual eventually decides to stop drinking completely, then might wean off the naltrexone over time or the topiramate, depending on which they found the most effective.
Dr. Mark Leeds [11:49] Okay. Yeah. So that might be a good solution, you know, for people that, you know, where, where the naltrexone might not be working well enough, that might be an add-on to consider for someone who’s still drinking.
Dr. Roland Engelbrecht [12:01] Yeah. And especially if someone’s using stimulants as well. So like if they’re drinking alcohol and when they do, they use cocaine or amphetamines. It’s often very useful to add topiramate in those situations.
Dr. Mark Leeds [12:14] Oh, okay. That’s really good to know. And now gabapentin, now that’s something I was thinking, it seems like several of these drugs, maybe they don’t work directly on the GABA receptor, but they have some kind of a connection to it, like they work around it or interact with it in some way gabapentin I think topiramate maybe and also acamprosate but they’re all they’re not the same thing they all work in different ways I guess with the GABA receptor
Dr. Roland Engelbrecht [12:40] Yeah yeah so yeah gabapentin actually has a similar structure to the gabas but it works on a calcium channel topiramate I think it’s if I remember correctly it’s a gabba a receptor agonist and an NMDA antagonist. Might have to fact check me on that. And acamprosate is, yeah, directly on the GABA receptors, yeah.
Dr. Mark Leeds [13:10] Okay, and that brings up another interesting thing. The benzodiazepines, you know, people generally with alcohol treatment, you know, people have called them like, that they’re like alcohol on a pill, you know, and people should definitely not take things like Valium or Xanax if they’re quitting drinking. Is that ever used in any way as a harm reduction method of like, if you’re not drinking, but you have anxiety that you’re self-treating, that a person might be treated with benzodiazepines for anxiety? Or is that like an absolute contraindication that someone with alcohol use disorder should not take those medications?
Dr. Roland Engelbrecht [13:42] Yeah, I would not use that while someone’s still drinking. I would only utilize it if you’re planning to do, yeah, for withdrawal management. I would not use it as a treatment.
Dr. Mark Leeds [13:55] So only in a very controlled setting during the, maybe the detox period. Yeah. Okay. That makes sense. So yeah, gabapentin, someone did ask for that once a patient was trying to do the Sinclair method and she came back in and told me that she had read that gabapentin would be a good, a good add on. And I know that it’s, you know, it is actually a controlled drug in a few states, I think. So, you know, maybe because it potentiates other drugs, but that is gabapentin is used for as an add-on possibly for naltrexone for someone who’s trying to slow down their drinking
Dr. Roland Engelbrecht [14:29] Yeah I find that gabapentin works well so if someone’s complaining of a lot of anxiety restlessness and insomnia adding on gabapentin helps a lot just to settle them down a bit and not kind of reach for the drink to settle themselves down
Dr. Mark Leeds [14:47] Okay okay great now And gabapentin also is helpful with opioid withdrawal symptoms. And another thing that they use for opioid withdrawal symptoms is clonidine. Does clonidine have any use at all in alcohol withdrawal or alcohol treatment or not?
Dr. Roland Engelbrecht [15:06] Yeah, you can use it in the, sorry, in the, when you’re managing withdrawal, but same as benzodiazepines, it’s not part of treatment, just part of the withdrawal management.
Dr. Mark Leeds [15:18] Okay. Okay. Yeah. That’s definitely, that’s good to know. Yeah. And I know, yeah, it seems like we’re getting like a little technical getting into all these different medications, but these patients are very smart. I mean, they talk about this stuff all the time, you know, like what about this medication? What about that? So, you know, it’s really, it’s a matter of educating the doctors and getting them to do a little research and look these things up to be willing to provide these different kinds of treatment.
Dr. Roland Engelbrecht [15:45] Yeah, no, I think it’s good to know about all the options because patients, like you said, patients will do their research because they don’t always find that they get the answers they need. And knowing about what is used when just makes everything a lot smoother.
Dr. Mark Leeds [16:02] Sorry, are you located in British Columbia?
Dr. Roland Engelbrecht [16:05] Yeah, I’m in British Columbia. I’m in a rural town called Williams Lake. So, yeah, unique setting, often different than working in an urban center.
Dr. Mark Leeds [16:18] I’ve actually had two other guests on the podcast that are located in British Columbia. One of them was Stephen Finlay, who I think he’s in Surrey, which he oversees a supervised consumption site there. I don’t know if you’re familiar with him. Mostly heroin addiction and fentanyl addiction. And they’ve had very good results with no overdose-related death. They handle overdoses very well and you know a lot of great recovery and you know they talk about you know similar to the podcast I was listening to where you were interviewing some people where they talk about that making a connection with people getting to know them to know their name and to you know create a relationship is an important part of helping people to recover.
Dr. Roland Engelbrecht [17:05] Yeah no I would definitely say that I think a big part of practicing addiction medicine is you realize that it’s so little about it’s actually about the substance. It’s about creating a connection, helping them create connections again and improving their functionality. And over time, if there’s a truth, their substance use will decrease automatically.
Dr. Mark Leeds [17:30] Yeah, yeah. And another guest who had been on previously, who’s also from British Columbia, Harry Derbitsky. And Harry Derbitsky uses the three principles, which I guess is a spiritual alternative to the 12 steps. And, you know, it’s talked about helping indigenous people in the area. And how do you feel about that? I know, I know some people don’t don’t feel great about the 12 step programs in Alcoholics Anonymous, because it’s not really in line with some of these harm reduction type treatments. Do you have recommendations for people as far as like, you know, what kind of groups and meetings they can go to form a network of recovery support?
Dr. Roland Engelbrecht [18:06] Yeah, it’s, I don’t have any, anything specific. I mean, you could, you can do AA, you can do SMART Recovery. There’s lots of groups you can attend that you can find online, especially now during the age of COVID, you don’t necessarily have to attend them in person. And there’s some online groups you can attend. But I would, I think, in principle, I would say it’s always good to involve some part of psychotherapy in your recovery. Medication can be very helpful, but on its own, it can be helpful, but it’s better to combine with psychotherapy. And then also working on basic lifestyle changes and improving your health in general.
Dr. Mark Leeds [19:00] Okay. And what kind of work is the Canadian Alcohol Use Disorder Society doing today? Like, do you go around lecturing to groups or individuals? You know, do you go around doing those kind of same lectures that Dr. Harris was doing?
Dr. Roland Engelbrecht [19:14] So not at the moment. I think a lot of it was been delayed because of COVID and just the inability to do in-person sessions. But that’s what we’re working towards is possibly doing some online workshops, creating educational material and then also doing two smaller PQI projects in our area where we starting to educate physicians on the use of these medications when a patient presents to the emergency department unfortunately there’s a lot of patients who are unattached don’t have family doctors so their only contact with healthcare system is when they go to the emergency unit so it would be a good place to just at least have the discussion about starting one of these medications and helping them along
Dr. Mark Leeds [20:03] Yeah have you are you familiar with any I think there might be at least one and maybe in north carolina a rehab that actually uses the sinclair method where they it’s hard to imagine like a facility doing that but there’s actually a rehab where they give naltrexone and alcohol in a control setting are you familiar with any facilities doing that right now?
Dr. Roland Engelbrecht [20:22] No, I’m not familiar with any facilities doing it, but it makes sense to me. I mean, it’s after seeing so many patients, it’s like everyone’s unique. You can’t try and fit everyone into one mold and force them to stop drinking and follow a program and then everyone’s going to be fine. Some people need to taper off. Some people need to do it slower while they work on their trauma and mental health. So it definitely makes sense to me.
Dr. Mark Leeds [20:51] Yeah, that makes sense. Now, in your regular daily practice, do you mainly treat people for addiction or is it mainly alcoholism or do you do more like general family medicine?
Dr. Roland Engelbrecht [21:04] Yeah, I used to do general family medicine, but unfortunately I had to step away from that just because my addiction medicine practice got so busy, unfortunately. So I mostly see people with opiate use disorder and then alcohol use disorder and then interspersed, sometimes stimulant use disorder as well.
Dr. Mark Leeds [21:23] Okay. Yeah. Oh, that was actually a really interesting topic of another podcast episode. A doctor from Indianapolis who has been studying the use of different things for stimulant disorder. And I know that’s cocaine use. You had mentioned a lot of people, they drink and then they go use cocaine. And yes, apparently there’s some different medications depending on the patient where medications that can help even with that with stimulant. I know that’s a whole other topic, but are you finding some success also in treating stimulant addiction with medications?
Dr. Roland Engelbrecht [21:56] Yeah, I feel stimulant use disorder. It’s difficult to treat with medications. I mean, the evidence is sparse in some ways on that topic. I’ve had some success with using topiramate. I’ve had some success with using combination of Wellbutrin and Naltrexone. There was actually a study published not too long ago about that and its effectiveness. So, yeah, that’s been good. But apart from that, yeah, those are basically the medications I would typically use.
Dr. Mark Leeds [22:33] Yeah. Yeah. I think I don’t remember the generic. I’m trying to think what Dr. Miller, he had two groups. He would separate the patients in two groups. And I think one group, they were the tired group, the low energy group, and they would get ProVigil and then get Remeron to help them sleep at night. And then the more common one was the ADD group, kind of the road range, angry people. And what was he giving them? He was giving them, it’s the one for ADD that’s non-controlled. It was 10x.
Dr. Roland Engelbrecht [23:07] It’s on Vyvanse, is it?
Dr. Mark Leeds [23:09] No, no, not Vyvanse. I’m going to have to edit this. What is that one? I think it’s the only one, kind of like an antidepressant. That’s like the only one that’s not controlled. Strattera, maybe? That’s it. Yeah, Strattera. Atomoxetine. Yeah, that combination was for most of the people, I think 85% of them. And he claimed that he had a high success rate, around 80% of people not having cravings after three days of treatment, which is interesting. I mean, I don’t know, but I haven’t tried any of it, really. But at least it’s interesting. You know, people are trying different things just to try to find something that might help with that. Because it’s, you know, like you said, there’s not really a lot of success in treating stimulant addiction with medication so far.
Dr. Roland Engelbrecht [23:55] Yeah. I mean, the base evidence is for contingency management. But, I mean, especially in the small town where I live, there’s nothing like that available. So, yeah, you have to try different things.
Dr. Mark Leeds [24:10] But, yeah, I mean, it’s great. I mean, of course, for opioid use disorder, we have like really great treatments that work incredibly well. And it’s just a matter of getting past the stigma associated with treatment. And now, of course, with alcohol use disorder, if we just don’t pressure the people too much, you know, like you said, not everybody’s ready to quit all at once. But some really great success with medications there. And it’s great to know that there’s so many alternatives. You know, if one thing doesn’t work, a combination of things might work or something, an alternative might work better. So it’s really important for doctors and patients to know, just to be aware of these things, that they can research them and learn more about them. Also, if someone is, maybe that’s probably the last thing to bring up, if someone is on opioids, maybe for chronic pain, of course they can’t take naltrexone because that’ll interfere with their opioid treatment. And say that they’re drinking a little bit, I guess it doesn’t sound like a good combination, they’re taking opioids for medical treatment and drinking, which isn’t good anyway. I guess the ideal thing there would be to get them to stop drinking as soon as possible. But I guess you have the topiramate, which would not block their opioid treatment, and they could take while they’re still slowing down the drinking.
Dr. Roland Engelbrecht [25:26] Yeah, I think it depends on the patient’s goals and where they’re at. If it was someone taking opioids for pain, yeah then using something like topiramate could be useful or even gabapentin might even help with their pain if it’s someone with an opiate use disorder on opiate agonist treatment then I would consider starting them on suboxone or buprenorphine if they’re not already on that because that But in a way, to oversimplify it could act as naltrexone in the system and also help them with those, with the cravings for alcohol as well. I’ve done that with patients in the past, but that’s kind of what I would think of when I see a patient with that.
Dr. Mark Leeds [26:15] Yeah, that’s a good point. The buprenorphine would give some of those same benefits of naltrexone. With the topiramate, what would be the typical dosing for that?
Dr. Roland Engelbrecht [26:24] Yeah, so topiramate, you start quite low. You do 25 milligrams once a day, and you slowly titrate it up by 25 milligrams a week, and you can go up to, I believe, 150 milligrams. But usually, target dose is around 50 to 100 milligrams a day. And when you reach 50 milligrams, you can start splitting it BID, so 50 milligrams twice a day.
Dr. Mark Leeds [26:54] Okay, great. Great. Yeah. So we talked about the dosing pretty much, I think for all of them, you know, the, well, naltrexone is usually 50 milligrams, I guess, up to a hundred milligrams, either daily or as needed. And then the, you had mentioned the dosing for gabapentin, topiramate, ondansetron and Campral, I think it is pretty much standard. Acamprosate is, I think, is it 300 milligrams? You take two of them three times a day. So it’s like,
Dr. Roland Engelbrecht [27:21] It’s a funny dose. It’s like it’s every tablet is 333 milligrams. So the dose is 666 milligrams three times a day.
Dr. Mark Leeds [27:33] Yeah. And now have you heard anything about this that it may be a good treatment to help people quit smoking?
Dr. Roland Engelbrecht [27:39] Yeah, I’ve heard about it. I haven’t used it yet. I’ve had great effect with Zyban and Champix. So I haven’t had to try something else, but yeah, I’ve read about it.
Dr. Mark Leeds [28:00] Okay, but it’s a pretty safe medication for someone who’s not drinking or not, you know, it’s pretty safe to take long-term at that dosage.
Dr. Roland Engelbrecht [28:07] Yeah, pretty safe. Main thing is just make sure they don’t have any renal impairment and that it isn’t a breastfeeding mother.
Dr. Mark Leeds [28:15] Oh, okay. Yeah, that’s important. Okay. Yeah, so, yeah, thank you for joining me. I mean, I’m sorry to keep you here so long, but that’s really incredibly useful information for a lot of people. And if someone wanted to reach you know, for, I mean, do you accept patients from, is it a private clinic or do you accept patients from all over?
Dr. Roland Engelbrecht [28:38] Yeah, I basically see people for consultations in my clinic here in Williams Lake. It’s usually just patients from around the area. But if people are looking for more information on alcohol use disorder and potential treatments that they can take to their own physicians, they could go to the CAUDS website, which is cauds.org. And we’re in the process of working on some more educational videos that we’ll put on the website as well. So it might be a useful resource for patients or even clinicians do like that.
Dr. Mark Leeds [29:12] Okay. Have you ever coordinated or worked at all with the C3 Foundation?
Dr. Roland Engelbrecht [29:15] No, no, we haven’t yet.
Dr. Mark Leeds [29:18] They actually recently had a virtual convention. It was really interesting. It was hosted on Twitch, which is normally a gaming network. And yeah, I was one of the speakers in that. And we didn’t have to go anywhere. We just sat in front of the computer and talked and had a chat room going. And it was a lot of fun. But yeah, it’s good for people to know that it’s not just in one organization that they can go look up. Are you pronouncing it CODS? C-A-U-D-S?
Dr. Roland Engelbrecht [29:50] C-A, yeah. Canadian Alcohol Use Disorder Society, yeah.
Dr. Mark Leeds [29:54] Yeah, you guys in Canada, especially British Columbia, are way more advanced than we are as far as treating addiction and harm reduction.
Dr. Roland Engelbrecht [30:01] Yeah, that’s nice to know. But we still have some ways to go.
Dr. Mark Leeds [30:06] Sometimes I tell people, you know, if you really can’t get help here, you might want to consider moving to Canada. Anyway, but yeah, thank you for joining me today.
Dr. Roland Engelbrecht [30:17] No, yeah, thanks for having me and thanks for the chat. Appreciate it.
