By David Brown
Washington Post Staff Writer
Tuesday, June 17, 2008
When it comes to treatment, the experts think alcoholism needs to catch up to depression.
Three decades ago, long before the dawn of the Prozac Era, depression was a disease rarely treated in its mild form, reluctantly treated with drugs and usually treated by experts only. Today, signs of depression are actively sought, drugs are prescribed early and often, and most cases are handled by non-psychiatrists.
With alcohol abuse, however, most physicians don't go looking for trouble and don't recognize it until it's breathing in their face. Over-drinking patients often don't think of looking for help even if they know they are heading in the wrong direction. And society as a rule looks at alcohol treatment as a last-chance, 90-degree corner taken only at high speed.
All this will change if American physicians adopt the new guidelines for "Helping Patients Who Drink Too Much" promulgated by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.
The idea is to simplify the screening for excessive alcohol use in general medical practice and to convince clinicians and patients that early intervention for drinking that hasn't yet wreaked havoc is both possible and useful.
"We're trying to increase the accessibility and attractiveness of treatment to a much broader spectrum of people," said Mark L. Willenbring, a psychiatrist who directs the Division of Treatment and Recovery Research at NIAAA.
Those especially targeted in the guidelines are heavy drinkers who are not yet physically dependent on alcohol but are at risk for becoming so.
"We know that that group responds very, very well to what we call facilitated self-change and brief motivational counseling. We could make that very widely available without much cost," Willenbring said.
A big part of the new strategy is to make primary care physicians -- people without specialized training in addiction medicine -- think about alcohol abuse the way many now think about depression, anxiety and obsessive-compulsive disorder. Which is to say, they need to think of it as something common, diagnosable and within their capacity to treat. The guidelines make this easy: The screening tool for alcohol problems consists of a single question. For men: How many days in the past year have you had five or more drinks? For women: How many days in the past year have you had four or more drinks?
"Most doctors don't know how to make the diagnosis and don't really try to do anything about it until it is so easy to diagnose that all you have to do is glance at the patient," said Charles P. O'Brien, a professor of psychiatry at the University of Pennsylvania who has been treating alcoholics for 38 years.
"It used to be said that you can't treat somebody until they are down and out. But when they are down and out, they are really hard to treat," O'Brien said.
"I think there is a belief that people with more moderate levels of dependence don't know they have a problem. I think they do. But they don't think rehab is the model of treatment for them -- and I don't, either."
The sort of therapy both advocate does not involve magic bullets or easy answers or effortless behavior change. But it does enlist pills that help a little, quite a bit of talk and lots of self-discipline.
And what does it get a person?
Perhaps not surprisingly, there's evidence that getting control of a drinking problem early can improve one's health, completely apart from the social, psychological and familial benefits it brings.
A study published two years ago looked at the experience of 628 men and women who entered alcoholism treatment (either in residential rehab or as outpatients) in their mid-30s and were followed for 16 years.
Over that period, 121 died, or 1.2 percent a year. The average age of death was 48. But the chance of dying was significantly lower in people who after the first year were abstinent or had no drinking-related problems or symptoms.
So how successful is treatment, or at least how successful has it been?
Researchers in 2000 analyzed seven studies, one going back to the late 1970s, in which more than 8,000 people were treated for alcoholism in various ways, including with drugs. After a single course of treatment, one-fourth were abstinent for at least a year and one-tenth dramatically decreased their drinking. The rest, about two-thirds of the subjects, drank less often and in quantities averaging less than half of what they consumed before treatment. Mortality in the first year was 1.5 percent.
Some of those patients had a four-week stay in "rehab," but most did not. A long treatment-center admission as the optimal strategy to stop a serious drinking problem is much more the model of the 1980s than the 2000s. The newer one emphasizes outpatient treatment -- occasionally after a brief hospital stay for acute detoxification, if necessary -- with care provided by non-specialists in many cases.
How often contemporary treatment succeeds was also explored in a complicated clinical trial of about 1,400 alcohol-dependent men and women, average age 44 and consuming 12 drinks a day, that was published in the Journal of the American Medical Association in 2006.
The researchers randomly assigned the patients to nine groups. Four of the groups got nine sessions, conducted by a doctor or nurse and lasting at least 20 minutes, that reviewed the health consequences of excessive drinking, encouraged abstinence and attendance at Alcoholics Anonymous meetings, and urged adherence to the study medicines. Four of the groups also got intensive counseling by alcohol-addiction experts -- up to 20 hour-long sessions.
Some of the patients were assigned to take a drug for three months: either naltrexone, which blocks opiate receptors in the brain that are involved in alcohol's "reward pathways," or acamprosate, which works through so-called GABA receptors to decrease the anxiety and restlessness that can come with abstinence. Some got placebo pills.
A year later, there were no big differences among any of the groups, although there were some interesting small ones. (This was true even with what the researchers considered the placebo group, the people who received specialized alcohol counseling but no time with a physician and no pills.)
People who met regularly with a doctor or nurse and then got either naltrexone or the intensive counseling did equally well; about 66 percent were abstinent. People who had those sessions and got placebos did less well; 59 percent were abstinent. Those who got intensive counseling but no pills, neither active ones nor placebos, had an intermediate outcome, with 62 percent abstinent.
Unlike some other studies, this one showed no benefit from acamprosate. But that may not be the last word.
A clinical trial not yet published showed the drug worked only when started during a period of abstinence, not while a person was still drinking. And last month researchers reported more evidence that GABA receptors play a role in alcohol addiction. Laboratory rats that got the drug gabapentin, which enhances the action of GABA, drank less -- but only if they were already chronically exposed to alcohol. Those that used alcohol only occasionally did not show such an effect, suggesting the preexisting state was crucial to the response.
Abstinence, in almost all practitioners' minds, is always the goal. But its absence doesn't signal abject failure.
"It is a fiction that the typical change process is a sudden transformation," Willenbring said. "The more common is a change process that lasts years and is characterized by lengthening periods of sobriety and shorter relapses until they are gone."
In that way, alcohol abuse is like depression. In another way, too.
"Recovery from depression requires effort. The same is true for alcohol dependence," he said.
And in both cases, he thinks they're really worth the effort.