Counseling and meds: New approach for alcoholism

Treatment outcomes for alcoholism are likely to improve significantly in the next decade. However, in order to provide these treatments, a new paradigm and structure are needed that will integrate alcohol treatment with mainstream medical and mental health care.

This message was delivered by Mark L.Willenbring, M.D., director of the division of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Willenbring was a speaker at the American Medical Association's media briefing, "Alcohol Dependence: From Science to Solutions," held recently in New York City.

Three medications are currently available to treat alcohol dependence: disulfiram (Antabuse, Odyssey), naltrexone HCl (ReVia, Bristol-Myers Squibb), and acamprosate (Campral, Forest). "These medications, when combined with counseling, significantly improve outcomes during early recovery. In the next 10 years, several more medications are likely to become available. The medications appear to work by correcting the imbalances in neurotransmitter systems caused by heavy drinking," said Willenbring.

Litten went on to say, "We are looking at a new generation of medications that can reduce one's urge or desire to drink. The most promising so far has been naltrexone. It appears that it can reduce craving, and there is evidence it reduces the positive reinforcement of drinking. Acamprosate works in a slightly different way. It can reduce abstracted abstinence, or withdrawal symptoms that can occur weeks or even months after one stops drinking."

Litten said NIAAA has completed a major clinical trial involving 1,383 alcohol-dependent patients to evaluate the combinations of naltrexone and acamprosate with behavioral therapies. Study results will be released later this year.

NIAAA is also funding several clinical trials with the following medications: topiramate, gabapentin, ondansetron, baclofen, rimonabant, kudzu (a Chinese herbal), and memantine. In addition, several clinical trials using combinations of medications are also under way.

Emphasizing that mental and medical disorders are not often identified and addressed in alcohol programs, Willenbring asserted that ideas about what alcohol disorders are, when they start, and how to prevent and treat them are rapidly changing. "Heavy drinking and alcohol-use disorders start early in life. These are disorders of young people." Research shows, he said, that the first symptoms of alcohol use disorders-abuse and dependence-are not as common in persons over 30 as they are in younger people.

Willenbring observed that prevention and treatment approaches must be tailored to individuals. "Most counseling approaches have approximately equal effectiveness, so the most important thing is making a decision to change, and then sticking with it. Some people require a single brief intervention. Other people require a period of more intensive counseling, while still others will need medications as well as counseling," he said.

Twenty-five years ago, Willenbring explained, depression was treated almost exclusively by psychiatrists, and only people with the most severe cases received treatment. Today most antidepressants are prescribed by primary care physicians. "I believe we may see a similar change in our field, especially as more medications become available."

In conclusion, Willenbring said, "We are on the cusp of a major shift in how we address heavy drinking and alcohol-use disorder." He maintained that we must continue to move toward fully integrating alcohol treatment into mainstream medical and mental health care and that the specialty addiction sector must gear up to provide systematic care for the most complex and difficult cases. "This is the model for other diseases," he said, "and I believe we will find it works in this one as well."

NIAAA is offering a 2005 clinician's guide, "Helping Patients Who Drink Too Much," which includes a section on drugs. Visit http://www.niaaa.nih.gov.