With the exception of those specializing in addiction, many psychiatrists
may not have had much training in alcoholism treatment in medical school and
residency. However, as psychiatrists know well, problems with alcohol are
common in a patient population, which makes alcoholism treatment important to
many psychiatrists' practices.
So what kinds of alcoholism treatments can psychiatrists offer patients
these days? Well, there is both bad news and good
news.
The bad news is that "there is no one approach that is particularly
better than another," Marc Schuckit, M.D., an alcoholism authority and
distinguished professor of psychiatry at the University of California, San
Diego, said in an interview. "At least the [scientific] literature to
date doesn't indicate that there is any simple way to match the treatment to
the specific patient."
The good news, however, is that there have never been so many good
treatment options for alcoholism, Schuckit and other alcoholism experts
agreed.
Disulfiram has long been available to deter people with alcoholism from
drinking. If people drink alcohol while taking this drug, however, they can
experience not only unpleasant but also potentially dangerous side effects. A
more generally tolerated drug was approved in 1995 by the Food and Drug
Administration (FDA)—naltrexone, which reduces alcohol craving.
In 2004 the FDA approved a third drug to treat
alcoholism—acamprosate—which had already been used in Europe for
this purpose. Like naltrexone, it reduces alcohol craving and is generally
well tolerated. And finally in 2006, the FDA approved the anticonvulsant drug
topiramate, which is used off label for treating alcoholism. It makes people
lose interest in drinking and is generally well tolerated.
Of the three newer alcoholism medications, "I think the strongest
evidence is for naltrexone in terms of there being the most studies and the
most positive studies," Henry Kranzler, M.D., said in an interview. He
is an addiction psychiatrist and associate scientific director of the
University of Connecticut's Alcohol Research Center.
Kranzler said that naltrexone is the medication he prefers to use to treat
individuals suffering from alcoholism because it's "safe, has
demonstrated efficacy, and has been approved for more than a decade."
Also of note: In a randomized controlled trial, naltrexone was found to be
significantly better than a placebo in helping American Indians and Alaska
Natives achieve abstinence from alcoholism. These results appeared in the June
28, 2008, Alcoholism: Clinical and Experimental Research.
Yet when it comes to the most robust alcoholism medicat ion, it is
topiramate, Kranzler said. It has been shown to be efficacious in treating
alcoholism in both a single-site study and a multicenter one.
Naltrexone, acamprosate, and topiramate are also helpful in that they can
help people reduce their alcohol intake even if they don't stop drinking
altogether, Kranzler said. But that does not mean "necessarily that one
would go into treatment recommending simply reduction," he cautioned."
Although for some people that does seem to be appropriate, for many
others, complete cessation is probably the only reasonable goal...."
Data indicate, too, that cognitive-behavioral therapy (CBT) can help
individuals with alcoholism, Schuck it reported. The regimen is focused on
handling thoughts about alcohol, dealing with urges to drink, refusing drinks,
and avoiding situations that might lead to relapse. Indeed, the
alcoholism-treatment program that Schuckit conducts at his university and at
the VA San Diego Healthcare System is based on a cognitive-behavioral
approach, he said.
Still useful is Alcoholics Anonymous (AA), which was founded in 1935 and
has some 2 million members worldwide. It is based on a 12-step approach to
recovery that includes admitting that one cannot control one's addiction,
recognizing that a greater "power" can give strength, turning
one's life over to that power, making a list of people one has harmed by
alcohol abuse and making amends to them if possible, and helping others who
also suffer from alcoholism.
Some good scientific evidence underscores AA's efficacy, although this
evidence has essentially become available only since 2000 or so, reported
Graeme Cunningham, M.D., at the annual meeting of the Canadian Psychiatric
Association in Vancouver last September. In addition to being a psychiatrist
and internist, Cunningham is director of the Addiction Division of Homewood
Health Center in Guelph, Ontario.
For example, a large sample of people entering ambulatory alcoholism
treatment for the first time, from referral or detoxification centers, were
evaluated at intervals of up to 16 years. Their participation in AA was found
to make a positive contribution to their outcomes independently of any other
treatments they received, Marc Galanter, M.D., a professor of psychiatry and
director of the Division of Alcoholism and Drug Abuse at New York University,
told Psychiatric News.
In another large-scale study of alcohol-dependent veterans, who were
initially treated as inpatients, their level of AA attendance within the first
year after admission predicted fewer alcohol problems at the two-year
follow-up, Galanter also reported. This effect was independent of their
previously measured motivation for change, suggesting that AA itself plays a
causative role in reducing drinking.
A large federal study called Project Match, where participation in AA was
simulated with a 12-step approach to conquering alcoholism, found such
participation as effective as CBT or motivational enhancement therapy in
achieving this end, Kranzler said. (Motivational enhancement therapy provides
structured feedback about alcohol-related problems and attempts to motivate a
patient to change, to increase personal responsibility, and to enlist personal
resources.)
In addition to medications and psychosocial therapies, there are a number
of effective alcoholism-treatment programs that deploy either or both
modalities.
For example, Hazelden in Minnesota, a highly respected treatment facility,
has helped people reclaim their lives from alcoholism since 1949. Hazelden
also has treatment facilities in Florida, Illinois, Oregon, and New York. The
treatment approach is an abstinence-based, 12-step one, with the goal of
achieving lifelong recovery from the illness. An interdisciplinary team of
professionals works with each patient to ensure that the team addresses all
aspects of his or her addiction as well as any co-occurring disorders that
affect the body, mind, or spirit.
Double Trouble in Recovery (DTR), a 12-step-based, mutual-aid fellowship
for people recovering from both alcoholism and mental illness, was recently
listed in the National Register of Evidence-Based Programs and Practice. Six
DTR groups, in fact, have been established as part of standard psychiatric
inpatient services at Woodhull Hospital in Queens, N.Y.
In Canada, there is Cunningham's residential alcoholism-treatment
program—the only residential alcoholism-treatment center in Canada that
includes AA participation in its treatment. Cunningham also launched a program
in 1990 to treat alcohol-dependent doctors and nurses. Since then, he has
treated several thousand of them, he told Psychiatric News.
In Germany, meanwhile, Hannelore Ehrenreich, M.D., Ph.D., a psychiatrist
with the Max Planck Institute of Experimental Medicine in Goettingen, along
with Henning Krampe, Ph.D., a psychologist there, designed a treatment program
for severely affected alcoholic patients called the Outpatient Long-Term
Intensive Therapy for Alcoholics (OLITA). The two-year treatment program is
run by an interdisciplinary team. It includes detoxification, frequent
individual therapy sessions, year-round 24-hour emergency service, the use of
disulfiram to deter drinking, regular urine and blood testing for alcohol, and
aggressive aftercare—say, unannounced home visits—after the
program has ended.
Ehrenreich and Krampe tested the effectiveness of the program on 180
persons with severe alcoholism (that is, 60 percent already suffered from
chronic pancreatitis, liver cirrhosis, or other grave consequences of the
illness). They found that a quarter of the subjects did not consume any
alcohol at all during the two years of treatment and seven years of follow-up,
and that 52 percent experienced only an occasional brief relapse during the
two years of treatment and seven years of follow-up. Ehrenreich explained,"
They drank, for example, a beer and then called us. We implemented an
emergency intervention, and they then continued their abstinence."
On the basis of the scientific evidence available, "I think the OLITA
program compares very favorably with, and appears to be much more effective
than, most other [alcoholism] intervention programs," Ivan Diamond,
M.D., Ph.D., an alcoholism expert in Palo Alto, Calif., and editor in chief of
Alcoholism: Clinical and Experimental Research, told Psychiatric
News. "I am impressed by their achievements."
"There are [also] similar programs in Austria, England, and
Switzerland, and we are in touch with them," Ehrenreich said."
There is a lot of interest [in them] all over the world, I would
say." ▪