Acamprosate vs naltrexone vs both

[medhead1990]

Hey, just wanted to start a conversation about these medicines. I tend to lean on naltrexone heavily in my practice in large part because that’s just what I’ve had the most experience with. I had someone in my office today who wants to get off alcohol but is on chronic opiates for back issues. (status post fusion) which made me consider reaching for acamprosate. I’ve written it for 5 or so people and I have never had a home run, but I have also never really had tons of negative to say about it.

I Did a quick search of the forums and overall found most people were not super excited about acamprosate the group tends to lean towards naltrexone. I saw no mention of doing both. Lit review seems to believe that acamprosate is better for staying sober and naltrexone with better evidence to reduce heavy drinking. I didn’t see anything about putting the two together other than something that also did CBT at the same time so didn’t really help from that regard.

Curious, what opinions are out there if any.

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[comp1]

There are no good meds. You can't do naltrexone with chronic opiates. So your choices are disulfiram and acamprosate. Disulfiram sucks. Also, you have the no meds choice since they have limited efficacy anyways.

 

[Merovinge]

Peer support in the community (12 step, recovery dharma, etc.) or structured through PHP/IOP are going to be the biggest bang for buck. Someone on chronic opioids s/p fusion with an alcohol use disorder would definitely be a good candidate for extra help beyond you writing a script.

 

[nexus73]

Why not try it. Also topiramate is an option off label. Probably avoid gabapentin with chronic opioids.

 

[Sushirolls]

Don't forget getting HST when on chronic opioids due to increased central apneas.

 

[littlefred]

Hey, just wanted to start a conversation about these medicines. I tend to lean on naltrexone heavily in my practice in large part because that’s just what I’ve had the most experience with. I had someone in my office today who wants to get off alcohol but is on chronic opiates for back issues. (status post fusion) which made me consider reaching for acamprosate. I’ve written it for 5 or so people and I have never had a home run, but I have also never really had tons of negative to say about it.

I Did a quick search of the forums and overall found most people were not super excited about acamprosate the group tends to lean towards Suboxone. I saw no mention of doing both. Lit review seems to believe that acamprosate is better for staying sober and naltrexone with better evidence to reduce heavy drinking. I didn’t see anything about putting the two together other than something that also did CBT at the same time so didn’t really help from that regard.

Curious, what opinions are out there if any.

I'm sorry but let's talk about the elephant in the room. Alcohol mixed with opiates can lead to an overdose/death. Does their opiate presciber know? In an ideal world they would do inpatient detox and then do acamprosate along with psychotherapeutic interventions.

 

[Liquid8]

Can't say I've had spectacular results with either, and would usually go with one first and then switch if it doesn't appear to be working. My gut feel is that Naltrexone has been marginally more effective so I'd tend to lean towards that where I can. Our acamprosate formulations require 6 tabs a day which can be tricky for patients and probably doesn't help compliance.

 

[whopper]

I've never had one patient take Acamprosate for an alcohol problem, and say they've found a noticable improvement due to the medication. The data showing Acamprosate works didn't show very good results, although better than placebo.

I'd recommend instead of simply just what you experience clinically to read the data from APA guidelines that did a very thorough examination of several options such as Topiramate Gabapentin, Acamprosate, and Disulfiram, then ranked then in terms of priority. Your own personal data matters for something, but shouldn't be a starting point.

You should actually read the material first and if you're post-training then do the clinical trials on your patients.

A major paradigm I saw change for the better while I was in training was the shift of psychiatrists from "I like that one cause I gave it out a few times and it worked" vs finally seeing more comprehensive data tha compared the efficacy of meds against others for treatment of the same disorders. E.g. CATIE and STAR*D. I spent years asking my teachers, why this antidepressant, and was never given an answer that was evidenced-based. "Oh I like it, that's why."

For decades psychiatry deserved it's place as a BS field when, for example, IM could do a study with hundreds of subjects on B-blockers to compare and contrast the efficacies of each B-blocker and track patients for years to see which ones had best survival rates, efficacies and such, while we were in the area of "I like Lexapro cause it's spiritual." Yes I actually heard some idiot say that who was a licensed professional.

The very fact that someone who was a trained medical provider could say something as idiotic as "I like" it cause "it's spiritual," and not get the deserved proverbial beheading this person would've deserved had this been said about a B-blocker in IM showed that our field had a long way to go. We still do, but with CATIE, STAR*D, STEP-BD, pharmacogenetic test, we've made some good progress.

 

[annoyedpsychiatrist]

If you look at the NICE guidelines, they like campril and are more optimistic about it. If you look at the data for here however, the data isnt very good for campril.

Multiple cons with campril:
1. TID dosing in patients that probably already have compliance issues
2. Whenever ive tried it, people get weird side effects and stop on their own
3. Not supposed to use it while actively drinking
4. if significant kidney issues, can prohibit use
5. Ive never had a single person go into remission/swear by it

Pros of campril:
1. Significant liver disease, perhaps better choice than naltrexone

Overall for AUD ive found naltrexone>campril. Ive had some people swear by naltrexone and others say it was useless. Ive had good luck with vivitrol but usually the people getting vivitrol are more highly motivated/have involved family which could be the reason why. Since its essentially a painful shot on the butt.



In my community health job prior to this, we had addiction groups. Those groups were the most useful tool for alcoholics because of the brotherhood factor/accountability, and I would say those were more effective than any medication.. I dont think medication is a replacement for motivation, you have to have strong motivation/desire to get clean, and medication is only an aide to that.

 

[littlefred]

I've never had one patient take Acamprosate for an alcohol problem, and say they've found a noticable improvement due to the medication. The data showing Acamprosate works didn't show very good results, although better than placebo.

I'd recommend instead of simply just what you experience clinically to read the data from APA guidelines that did a very thorough examination of several options such as Topiramate Gabapentin, Acamprosate, and Disulfiram, then ranked then in terms of priority. Your own personal data matters for something, but shouldn't be a starting point.

You should actually read the material first and if you're post-training then do the clinical trials on your patients.

A major paradigm I saw change for the better while I was in training was the shift of psychiatrists from "I like that one cause I gave it out a few times and it worked" vs finally seeing more comprehensive data tha compared the efficacy of meds against others for treatment of the same disorders. E.g. CATIE and STAR*D. I spent years asking my teachers, why this antidepressant, and was never given an answer that was evidenced-based. "Oh I like it, that's why."

For decades psychiatry deserved it's place as a BS field when, for example, IM could do a study with hundreds of subjects on B-blockers to compare and contrast the efficacies of each B-blocker and track patients for years to see which ones had best survival rates, efficacies and such, while we were in the area of "I like Lexapro cause it's spiritual." Yes I actually heard some idiot say that who was a licensed professional.

The very fact that someone who was a trained medical provider could say something as idiotic as "I like" it cause "it's spiritual," and not get the deserved proverbial beheading this person would've deserved had this been said about a B-blocker in IM showed that our field had a long way to go. We still do, but with CATIE, STAR*D, STEP-BD, pharmacogenetic test, we've made some good progress.

There's one for alcohol that has a nice acronym too... COMBINE.

 

[comp1]

I would have so many questions for anyone describing Lexapro as spiritual.

 

[vanfanal]

It well known that Acamprosate has multiple meta-analyses and also a Cochrane review which supports its use and efficacy. The interesting thing is that the positive trials seem to come out of Europe and are no replicated in North America or Australia. There are many proposed reasons for this. But overall I use it often when naltrexone canno be used; more so that gabapentin and I find it's better tolerated than topiramate, though topiramate is also a completely valid option. I will use in in active drinkers and when I was doing consults as a fellow, would even start it during detox.

 

[whopper]

One more thing about Acamprosate. Sometimes people are like WTF when they see the 666 mg dosing. Why not 700 mg? No they went with 666 mg. You may on occasion get someone with some type of superstitious streak in them bring up the 666.

 

[psycho-matic]

Hey, just wanted to start a conversation about these medicines. I tend to lean on naltrexone heavily in my practice in large part because that’s just what I’ve had the most experience with. I had someone in my office today who wants to get off alcohol but is on chronic opiates for back issues. (status post fusion) which made me consider reaching for acamprosate. I’ve written it for 5 or so people and I have never had a home run, but I have also never really had tons of negative to say about it.

I Did a quick search of the forums and overall found most people were not super excited about acamprosate the group tends to lean towards Suboxone. I saw no mention of doing both. Lit review seems to believe that acamprosate is better for staying sober and naltrexone with better evidence to reduce heavy drinking. I didn’t see anything about putting the two together other than something that also did CBT at the same time so didn’t really help from that regard.

Curious, what opinions are out there if any.

My n=1 with acamprosate in a patient naltrexone-induced severe nausea was successful. He swore by it and did well on it. He did make a joke about 666 mg. Gapapentin is worth trying and may actually help decrease opioid consumption by reducing neuropathic pain. It also has an anxiolytic effect.

 

[SubzDoc]

In my mind, there are essentially 3 pharmacological options for AUD. There is naltrexone/Vivitrol. There is disulfiram. The last category is medications that are essentially mild sedatives, NMDA-antagonists and/or mildy GABAergic drugs. This would include gabapentin and acamprosate, but also other medications we use off-label for AUD like lamictal, topiramate. You could argue baclofen could fit in there. There are medications that have been studied that don't fit into this 3-mechanism model, like zofran.

I don't think the last category, the mild sedatives, work very well. When I use them, I find that people will say they help with cravings, sometimes with anxiety/insomnia. But when I get down to the hard numbers, how much are they drinking and how often, they don't seem to make much of an objective difference in terms of alcohol intake. Not in terms of total intake or heavy drinking or relapse, I'm not convinced they do much. I don't add naltrexone and acamprosate because COMBINE even suggested the combo is no more effective. I still try to augment naltrexone sometimes with gabapentin and I don't get great results. I rarely try topiramate for some reason.

Disulfiram can work if you follow the guidelines. Generally, I think it works better in patients who are motivated and can sort of be trusted not to drink. But there needs to be accountability for the administration. Usually, this is a spouse, who will agree to watch the patient administer the patient every single day. It has gotten to the point that I won't prescribe disulfiram unless there is somebody who agrees to monitor the administration. I had plenty of patients say, "I'm really good at taking meds, I'll comply, etc." Inevitably, they just stop taking disulfiram when they want to drink. But disulfiram can work well when it is used correctly.

 

[clausewitz2]

In my mind, there are essentially 3 pharmacological options for AUD. There is naltrexone/Vivitrol. There is disulfiram. The last category is medications that are essentially mild sedatives, NMDA-antagonists and/or mildy GABAergic drugs. This would include gabapentin and acamprosate, but also other medications we use off-label for AUD like lamictal, topiramate. You could argue baclofen could fit in there. There are medications that have been studied that don't fit into this 3-mechanism model, like zofran.

I don't think the last category, the mild sedatives, work very well. When I use them, I find that people will say they help with cravings, sometimes with anxiety/insomnia. But when I get down to the hard numbers, how much are they drinking and how often, they don't seem to make much of an objective difference in terms of alcohol intake. Not in terms of total intake or heavy drinking or relapse, I'm not convinced they do much. I don't add naltrexone and acamprosate because COMBINE even suggested the combo is no more effective. I still try to augment naltrexone sometimes with gabapentin and I don't get great results. I rarely try topiramate for some reason.

Disulfiram can work if you follow the guidelines. Generally, I think it works better in patients who are motivated and can sort of be trusted not to drink. But there needs to be accountability for the administration. Usually, this is a spouse, who will agree to watch the patient administer the patient every single day. It has gotten to the point that I won't prescribe disulfiram unless there is somebody who agrees to monitor the administration. I had plenty of patients say, "I'm really good at taking meds, I'll comply, etc." Inevitably, they just stop taking disulfiram when they want to drink. But disulfiram can work well when it is used correctly.

Just to clarify, gabapentin does not meaningfully bind to GABA-receptors, despite structural similarities.

 

[allantois]

I’ve had decent results with Wellbutrin. Have never seen the other stuff work

 

[SubzDoc]

Just to clarify, gabapentin does not meaningfully bind to GABA-receptors, despite structural similarities.

Correct, the literature on the MOA of gabapentin is that it essentially opposes glutamate activity or is even possibly an NMDA antagonist, which is also what I said.

 

[psycho-matic]

I’ve had decent results with Wellbutrin. Have never seen the other stuff work

My concern with bupropion in the setting of alcohol abuse is the decrease in seizure threshold.

 

[comp1]

My concern with bupropion is grinding it up and snorting it.

 

[annoyedpsychiatrist]

Definitely people with polysubstance use, i start getting mighty skeptical when the only thing that works is wellbutrin/seroquel/artane.

 

[vanfanal]

I hear the XL formulation isn't very fun to snort. It burnsssss.

 

[Stagg737]

I'm all about less being more. The TID dosing without patients being able to perceive a difference makes it a lot harder to sell. Combine that with the generally poor efficacy and it's become a med I only use when there aren't any other options or patients ask for it. For AUD specifically I've found naltrexone (PO or vivitrol) >>> gabapentin >>>>>>>topiramate > everything else.

Naltrexone is once daily and sometimes works really well. Gabapentin is TID dosing, but also is somewhat anxiolytic and at least somewhat protective if they start drinking again and could withdraw. Plus you can get a decent bang for your buck even with pretty low dosing (300mg TID) and have a lot more flexibility with dosing. While I would be cautious mixing gabapentin with opioids, I'd feel a lot better about my patients taking a controlled dose of those and staying sober than mixing opioids with alcohol use, especially if they're binging or using high volumes.

 

[Merovinge]

I'm all about less being more. The TID dosing without patients being able to perceive a difference makes it a lot harder to sell. Combine that with the generally poor efficacy and it's become a med I only use when there aren't any other options or patients ask for it. For AUD specifically I've found naltrexone (PO or vivitrol) >>> gabapentin >>>>>>>topiramate > everything else.

Naltrexone is once daily and sometimes works really well. Gabapentin is TID dosing, but also is somewhat anxiolytic and at least somewhat protective if they start drinking again and could withdraw. Plus you can get a decent bang for your buck even with pretty low dosing (300mg TID) and have a lot more flexibility with dosing. While I would be cautious mixing gabapentin with opioids, I'd feel a lot better about my patients taking a controlled dose of those and staying sober than mixing opioids with alcohol use, especially if they're binging or using high volumes.

I find Gabapentin to be fairly effective even on a BID dosing schedule (e.g. 0900, 1700) when being used for anxiety. I treat adolescents with AUD/CUD who need extra anxiolytic effect with it and they often report stable improvement on BID dosing, although I am happy to move to TID dosing if they want to. It's a tough medication to keep at a stable blood level without QID dosing, but just having the effect each day on schedule has been anecdotally helpful in my patient population.

 

[psycho-matic]

I'm all about less being more. The TID dosing without patients being able to perceive a difference makes it a lot harder to sell. Combine that with the generally poor efficacy and it's become a med I only use when there aren't any other options or patients ask for it. For AUD specifically I've found naltrexone (PO or vivitrol) >>> gabapentin >>>>>>>topiramate > everything else.

Naltrexone is once daily and sometimes works really well. Gabapentin is TID dosing, but also is somewhat anxiolytic and at least somewhat protective if they start drinking again and could withdraw. Plus you can get a decent bang for your buck even with pretty low dosing (300mg TID) and have a lot more flexibility with dosing. While I would be cautious mixing gabapentin with opioids, I'd feel a lot better about my patients taking a controlled dose of those and staying sober than mixing opioids with alcohol use, especially if they're binging or using high volumes.

I wonder if there's any data to support pregabalin`s use in AUD, given its similarity to gabapentin and it can be dosed BID.

 

[whopper]

I wonder if there's any data to support pregabalin`s use in AUD, given its similarity to gabapentin and it can be dosed BID.

IMHO a reasonable extrapolation given the similiarties. I haven't seen any empirical data, but I had one patient get an allergic reaction to Gabapentin, but told me it was a "miracle" to help him stop drinking.

So I tried Pregablin on in him and it had the same benefits without the bad reaction. Often times this is how medicine advances. Doctors extrapolate, and yes we're going to not always have success, but sometime we will.

 

[ObsequiousAplomb]

IMHO a reasonable extrapolation given the similiarties. I haven't seen any empirical data, but I had one patient get an allergic reaction to Gabapentin, but told me it was a "miracle" to help him stop drinking.

So I tried Pregablin on in him and it had the same benefits without the bad reaction. Often times this is how medicine advances. Doctors extrapolate, and yes we're going to not always have success, but sometime we will.

what allergic reaction?

 

[littlefred]

what allergic reaction?

Probably swelling of lower extremity 😅

 

[whopper]

what allergic reaction?

Happened years ago so now I don't remember the specifics of the reaction, but he had a bad reaction on Gabapentin. Pregablin he was fine and showed all the expected benefits he would've with drinking alcohol on a low dosage of Pregabalin. (edit-meant to write Gabapentin).

 

[uhmocksuhsillen]

I've really gone in on baclofen recently. Find it very helpful when naltrexone has failed.

 

[ObsequiousAplomb]

I've really gone in on baclofen recently. Find it very helpful when naltrexone has failed.

I'm sure you're basing that on evidence that baclofen could be helpful. I'm too scared since baclofen overdoses are for whatever reason like 1/4 of the overdoses I've been seeing as inpatients lately. I'd hate to be jumping on the bandwagon for baclofen the way people were on the gabapentin bandwagon 5-10 years ago before the FDA finally admitted it can contribute to fatal overdoses.

 

[splik]

I've really gone in on baclofen recently. Find it very helpful when naltrexone has failed.

You would have a hard time defending yourself if there were a bad outcome given the evidence that the harms of using it for AUD vastly outweigh potential benefits in most cases. You probably want to be trialing other options if naltrexone has failed before going to baclofen.

 

[uhmocksuhsillen]

You would have a hard time defending yourself if there were a bad outcome given the evidence that the harms of using it for AUD vastly outweigh potential benefits in most cases. You probably want to be trialing other options if naltrexone has failed before going to baclofen.

Is it really a deviation from standard of care though in a patient who has failed other medications and/or has difficult to treat AUD? This was commonly done by one of our fellowship trained addiction docs in residency.

 

[Stagg737]

Is it really a deviation from standard of care though in a patient who has failed other medications and/or has difficult to treat AUD? This was commonly done by one of our fellowship trained addiction docs in residency.

I am not addictions trained, but I have never seen or heard of baclofen being used specifically for AUD...

 

[uhmocksuhsillen]

I am not addictions trained, but I have never seen or heard of baclofen being used specifically for AUD...

It's certainly not extremely common.

This is a brief overview on it.

The Use of Baclofen as a Treatment for Alcohol Use Disorder: A Clinical Practice Perspective

Alcohol use disorder (AUD) is a brain disorder associated with high rates of mortality and morbidity worldwide. Baclofen, a selective gamma-aminobutyric acid-B (GABA-B) receptor agonist, has emerged as a promising drug for AUD. The use of this drug remains ...

www.ncbi.nlm.nih.gov

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012557.pub3/full

"High‐certainty evidence found that baclofen increases the percentage of days abstinent (mean difference (MD) 9.07, 95% CI 3.30 to 14.85; 16 studies, 1273 participants). This result was confirmed among all subgroups of participants except non‐detoxified or those who received medium doses."

 

[vanfanal]

Used in Europe, France especially, quite a bit. They also use carbamazepine a lot for withdrawal. I think it's not completely out there and it certainly is used, but I always think you have to bet that someone will drink on a medication you give at least in the beginning; and from that perspective naltrexone, Acamprosate and even gabapentin are safer...imho.

 

[splik]

Is it really a deviation from standard of care though in a patient who has failed other medications and/or has difficult to treat AUD? This was commonly done by one of our fellowship trained addiction docs in residency.

It was in vogue in the past, but there was french study some years ago that found increased rates of hospitalization and death when used for AUD. It is licensed for alcoholism in France but the evidence is pretty weak and because of the risk of harm outweighing benefits it is not usually recommended. I think you could argue to use it in some cases (and it was used more commonly in the past in the US and I do think it can be beneficial in some cases), but you would have a hard time defending yourself in a malpractice case unless you had exhausted all other options. the APA guidelines on AUD specifically mention naltrexone, acamprosate, disulfiram, topiramate and gabapentin. So you would want to use those first, or if contraindicated, document that as well as having documented with patient that you discussed the limited evidence for baclofen and potential increased risk of hospitalization and death.

 

[whopper]

Just giving my clinical experiences.
Naltrexone: There's gene data showing people with a specific gene (forgot which one, but since it's not regularly tested we likely will not know it in the office) respond much better to Naltrexone. That gene is tested on some pharmacogenetic tests but not on the main one used by psychiatrists-Genesight.

I've seen several people where it's worked brilliantly and almost immediately, and several people with no benefits with plenty of side effects. While it almost always makes alcohol not enjoyable to drink, several people (and the gene data suggests it's because of the specific gene) while on it don't even want to drink anymore.

Gabapentin: Works often not just for alcohol abuse, but for opioid dependence, and anxiety. The problem is that the correct dose highly varies per patient. One patient is fine on 300, the next fine on 2400 mg a day. It takes playing around with the dose to find an optimal dose for the patient.

Acamprosate: Never had a patient tell me they noticed an improvement. Not one. I've tried it a few hundred times.

Disulfiram: Works, almost always so, but we know why and it can cause liver problems. Also several people get bad side effects from it making it intolerable. If the patient is compliant and reliable, they could be recommended to employ the Sinclair method that could further reduce side effects and increase compliance.

Topiramate: Works, but like Gabapentin the dose has to be played around with quite a bit. So if you try a starting dosage and there's no benefit that doesn't mean this med will not work. I'd only give up on it if you reached the max dose with no benefit, or a dose where there's no benefit and there's no point in raising it further because of side effects.

Now all of this said, you shouldn't just rely on a "some guy told me it worked." You should rely on evidenced-based data first and the APA guidelines on treating alcohol abuse IMHO is the best place to start.

 

[clausewitz2]

Just giving my clinical experiences.
Naltrexone: There's gene data showing people with a specific gene (forgot which one, but since it's not regularly tested we likely will not know it in the office) respond much better to Naltrexone. That gene is tested on some pharmacogenetic tests but not on the main one used by psychiatrists-Genesight.

I've seen several people where it's worked brilliantly and almost immediately, and several people with no benefits with plenty of side effects. While it almost always makes alcohol not enjoyable to drink, several people (and the gene data suggests it's because of the specific gene) while on it don't even want to drink anymore.

Gabapentin: Works often not just for alcohol abuse, but for opioid dependence, and anxiety. The problem is that the correct dose highly varies per patient. One patient is fine on 300, the next fine on 2400 mg a day. It takes playing around with the dose to find an optimal dose for the patient.

Acamprosate: Never had a patient tell me they noticed an improvement. Not one. I've tried it a few hundred times.

Disulfiram: Works, almost always so, but we know why and it can cause liver problems. Also several people get bad side effects from it making it intolerable. If the patient is compliant and reliable, they could be recommended to employ the Sinclair method that could further reduce side effects and increase compliance.

Topiramate: Works, but like Gabapentin the dose has to be played around with quite a bit. So if you try a starting dosage and there's no benefit that doesn't mean this med will not work. I'd only give up on it if you reached the max dose with no benefit, or a dose where there's no benefit and there's no point in raising it further because of side effects.

Now all of this said, you shouldn't just rely on a "some guy told me it worked." You should rely on evidenced-based data first and the APA guidelines on treating alcohol abuse IMHO is the best place to start.

Re: the gene issue, you may be confusing naltrexone and topiramate. Also, the Sinclair method is based on naltrexone, not disulfiram.

 

[wellbutrin.girlfriend]

Re: the gene issue, you may be confusing naltrexone and topiramate. Also, the Sinclair method is based on naltrexone, not disulfiram.

I've heard of people using disulfiram on a PRN basis, taking it before they go into an environment that's at high risk for return to use so that they have less temptation, knowing they'll get sick if they drink. Wondering if that's what whopper was referring to with Sinclair method and disulfiram.

That said, I hadn't heard of the Sinclair method before-- would be curious to hear anecdotes you all have of any patients who have tried this!

 

[whopper]

Also, the Sinclair method is based on naltrexone, not disulfiram.

Sinclair method, yes, and the inventor of the Naltrexone I believe is a Sinclair, but same principle with Disulfiram. If a guy only drinks on a Friday night he could possibly only take it on Friday morning.

This method only works well on patients with good insight.

 

[clausewitz2]

Sinclair method, yes, and the inventor of the Naltrexone I believe is a Sinclair,

Nope, John David Sinclair most definitely did not invent naltrexone.

but same principle with Disulfiram. If a guy only drinks on a Friday night he could possibly only take it on Friday morning.

Gotta disagree with you. The Sinclair method is based on the principle of extinction of the opioid-driven reinforcement of alcohol consumption. It does not produce an aversive effect. It actually doesn't work as intended if the person in question avoids alcohol completely, at least at first.

Disulfiram on the other hand is straight up positive punishment for alcohol consumption. These may seem like fine distinctions but they have significant impact on the kind of behavioral consequences you can expect as a result.

 

[ObsequiousAplomb]

Naltrexone was first synthesized in 1963 by Endo Laboratories, which was acquired by DuPont in 1969. Endo Laboratories was located in Garden City, New York.

In 1963, John David Sinclair was an undergraduate at the University of Cincinnati.

I'm fairly certain John David Sinclair wasn't also working at Endo Laboratories in New York while he was still in undergrad in Ohio.

 

[tennisall]

Given the long half life of acamprosate, why aren’t we seeing 999mg BID? Tolerability?

 

[Sikrouf]

I work in France nearby an addiction clinic where the baclofen salesman is sharing a lot of time with the practicionners

I ve seen it pushed 200-250mg a day very frequently
Cant remember it being useful once

 

[Merovinge]

I work in France nearby an addiction clinic where the baclofen salesman is sharing a lot of time with the practicionners

I ve seen it pushed 200-250mg a day very frequently
Cant remember it being useful once

Pardon my curiosity but how does that work in France? Baclofen is so old and very generic, how do they have salesmen or make money off of it? I always love hearing how other western countries practice medicine so thanks in advance.