Relapse Prevention in Alcoholism : Recent Advances and Future Possibilities

Most psychotropic drugs, such as antipsychotics, lithium and tricyclic antidepressants, do not improve alcohol (ethanol) abstinence rates, at least in alcohol-dependent patients who do not have a comorbid psychiatric disorder. In recent years, numerous studies have been published that have focused on the effect of alcohol on various neurotransmitters. The glutamatergic, opioid-endorphin, mesolimbic dopamine, and serotonergic systems are believed to be of special relevance to the positive reinforcing effects of alcohol and clinical phenomena such as craving. Based on these neurobiological and molecular-biological findings, and some preclinical findings, a number of pharmacological agents have been tested to assess their potential in reducing relapse in alcoholism.To date, the glutamatergic modulator acamprosate and opioid antagonists naltrexone and possibly nalmefene show the most promise as anti-craving drugs. Both acamprosate (in most European countries) and naltrexone (in the US, Canada and Austria) have been introduced into clinical practice and can be considered drugs of first choice.Some studies indicate that buspirone is effective in reducing symptoms of anxiety in alcohol-dependent individuals, although a significant effect on alcohol intake has not been reported in all studies. Most studies of the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors have found that these drugs have no effect on abstinence rates, but that they may have their place in the treatment of alcohol-dependent patients who have comorbid depression (fluoxetine) and cognitive deficits (possibly fluvoxamine). The therapeutic potential of other possible anti-craving drugs such as serotonin receptor agonists (e.g. buspirone) and antagonists (e.g. ondansetron) and dopaminergic drugs (e.g. bromocriptine, flupenthixol) needs to be examined in more detail.