PAUL-R-LINDE-MD















  1. Lots of folks here and in support groups like AA loathe the rehab/psychiatric industry — seeing it as a colossal failure brought about by gross misconduct, greed and laziness.

  2. Since I'm not a member of this subreddit, I don't know exactly what's been covered. Nonetheless, here are a few examples.

  3. It is considered a drug of abuse in opioid-using populations but I have only very rarely seen it misused in a heavy drinking population. It's considered a controlled substance in 7 states, all of which have high opioid-using populations.

  4. I hope you don’t mind me asking another question! What are your thoughts on the recent recommendations that came out of Health Canada on safe levels of alcohol use? They dropped their recommendation for low risk drinking down to 2 units a week, which is far less than the US and UK. Curious if there was any debate around that in the medical community?

  5. I wasn't aware of that recommendation. Of course, no alcohol is safest of all. I've been pretty satisfied with the current CDC/WHO risk guidelines especially as the NIH's alcohol recovery arm, the NIAAA, has redefined the terms of recovery to include an avoidance of heavy/binge episodes. I have treated many patients now who've come into the program drinking 6 to 10 (or even more drinks) every evening who eventually get down to no more than 3 (perhaps 4) once or twice a week (or only on special occasions). I like to give them a lot of encouragement and props for improving their health and relationships drastically by avoiding binges that I prefer guidelines that hew to a more harm reduction message. Also, to note, a lot of folks who start with a harm reduction intention eventually choose abstinence, which, in my opinion, is also a form of harm reduction.

  6. Thanks for doing this AMA. Have there been any studies done on the longer term impact of naltrexone on memory or dementia?

  7. That's a good question. Not to my knowledge. Naltrexone has been on the market for 38 years and has not been identified as a medicine causing cognitive problems according to adverse effects/outcomes reporting. Alcohol, of course, is highly associated with cognitive disorders so any reduction in alcohol use has benefits to our brain health (mood, anxiety, cognition) not to mention liver, heart, bone marrow, endocrine system, etc.

  8. Not that I know of, but there is no data. Yes, kratom does have opioid properties and should NOT be taken with naltrexone as you will get a very unpleasant opioid withdrawal experience in mixing the two.

  9. Sounds like you are off to a good start. More time on the medication will generally yield more positive results.

  10. This is a great and common question. For some reason, naltrexone generally does not diminish pleasure for other enjoyable activities or substances. In rare cases, it can cause significant depression and even suicidal thoughts but in general it seems to target the pleasure response from alcohol and not much else. I am not sure why this is but have seen it over and over again with prescribing naltrexone.

  11. There are some people who do get significant anxiety and irritability on naltrexone. If this doesn't reduce within 3-5 days likely you should stop the medication and try an alternative such as gabapentin which can reduce both drinking and anxiety. You should consult with whoever is prescribing the naltrexone.

  12. Good for you! Looks like a lot of good advice here from your peers.

  13. Naltrexone on a long-term basis and can definitely be used for relapse prevention. The naltrexone should reduce the cravings. Acamprosate (Campral) also has a role and may work even better.

  14. Congratulations! TSM is a legitimate option for reducing and eventually quitting alcohol if that is your goal.

  15. This a very common side effect -- nausea, GI upset, heartburn, etc. Taking the lowest dose possible of a quarter pill, 12.5 mg, and also with a fair amount of food should help. The food is not required for absorption but will definitely alleviate some of the stomach upset.

  16. Acamprosate is not prescribed often enough even though it is FDA-approved for heavy drinking. It seems doctors are not very experienced with it. It tends to work best to maintain sobriety as opposed to drink reduction but it can be prescribed for reduction as well. It has its own set of side effects as well -- mainly gastrointestinal but can also worsen depression. As a side note, gabapentin helps people reduce drinking and also works for anxiety as a non-addictive medication as compared to benzodiazepines.

  17. Sedation is a common side effect of naltrexone. It should get better over time. You can try a reduced dose of 12.5 mg (it is a challenge breaking it into a quarter pill but close is good enough) and also hopefully you will get used to the sedative effect over time.

  18. Sorry I missed you! My MD put me in Topamax for AUD but I am struggling with side effects notably cognitive issues even on the low dose of 25 mg. what's my prognosis if I cant get to the higher doses that supposedly work for cravings? I cant handle the cognitive issues. I need to be sharp for work....

  19. A fair number of people will not be able to tolerate higher doses of Topamax due to this side effect. So if it's significant, you'll want to discuss the side effect with your doctor to make a decision. There are alternative medication strategies to consider in that discussion.

  20. Thanks for your response, NAl was difficult for me to tolerate was well. Baclofen was very sedating, For reference I am a 5 foot 120 lbs woman and feel like I am out of options in terms of meds. Are there any other meds I missing here...I have heard low dose zofran might be a contender but don't know much it

  21. Yes, low dose Zofran (ondansetron) is being studied to reduce heavy drinking. I've not prescribed it before. Three other potential medications to try include acamprosate (Campral), which is most often used to maintain abstinence/prevent relapses, topiramate (Topamax), and gabapentin. The latter two can make one drowsy and/or fatigued.

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