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New Advances in Alcoholism Treatment
More than 700,000 Americans receive alcoholism treatment on any given day.
However, the techniques of alcoholism therapy have traditionally been based
on clinical experience and intuition, with little rigorous validation of
their effectiveness. Over the past 20 years, modern methods of evaluating
medical therapies have been increasingly applied to alcoholism treatment.
These methods include the use of control groups for comparison purposes,
random assignment of study participants to different treatment groups and,
to the greatest extent possible, follow-up of all patients who entered the
study. This issue focuses on the results of recent controlled clinical
studies on the effectiveness of self-help groups, psychosocial approaches,
and medications in achieving and maintaining abstinence.
Twelve-Step Self-Help Programs
Self-help groups are the most commonly sought source of help for
alcohol-related problems. Alcoholics Anonymous (AA), one of the most
commonly known self-help groups, outlines 12 consecutive activities, or
steps, that alcoholics should achieve during the recovery process.
Alcoholics can become involved with AA before entering professional
treatment, as a part of it, or as aftercare following professional
treatment. Although AA appears to produce positive outcomes in many of its
members, its efficacy has rarely been assessed in randomized clinical
One randomized study of patients entering employee assistance programs
compared inpatient treatment combined with AA with referral to AA alone.
This study found that inpatient treatment, a combination of professional
treatment and AA, will achieve better results for more people than AA alone.
Ouimette and colleagues, as part of a nonrandomized observational study
involving 3,000 patients in Department of Veterans Affairs hospitals,
compared predominantly 12-step programs with predominantly
cognitive-behavioral programs as well as with courses of therapy that
combined both approaches. In cognitive-behavioral therapy (CBT), the
therapist helps the client learn new skills to cope with problems and to
change harmful behavior patterns, such as alcohol abuse. One year after
completion of treatment, the three types of programs had produced comparable
improvements on measures of alcohol consumption and related problems.
However, participants in the 12-step programs achieved more sustained
abstinence and higher rates of employment compared with participants in the
other two programs. Interpretation of these results is complicated by the
nonrandom assignment of patients to the different treatment types.
The beneficial effects of AA may be attributable in part to the replacement
of the participant's social network of drinking friends with a fellowship of
AA members who can provide motivation and support for maintaining
abstinence. In addition, AA's approach often results in the development of
coping skills, many of which are similar to those taught in more structured
psychosocial treatment settings, thereby leading to reductions in alcohol
The following sections deal with selected recent approaches or
considerations relevant to the psychosocial treatment of alcohol-related
Motivational Enhancement Therapy
Developed specifically for Project MATCH,1 motivational enhancement therapy
(MET) begins with the assumption that the responsibility and capacity for
change lie within the client. The therapist begins by providing
individualized feedback about the effects of the patient's drinking. Working
closely together, therapist and patient explore the benefits of abstinence,
review treatment options, and design a plan to implement treatment goals.
Analysis suggests that MET may be one of the most cost-effective of
available treatment methods. In one study, the motivational interviewing
technique-a key component of MET-was shown to overcome patients' reluctance
to enter treatment more effectively than did conventional techniques.
Evidence indicates that involvement of a nonalcoholic spouse in a treatment
program can improve patient participation rates and increase the likelihood
that the patient will alter drinking behavior after treatment ends.
There are various approaches to marital family therapy. Behavioral-marital
therapy (BMT) combines a focus on drinking with efforts to strengthen the
marital relationship through shared activities and the teaching of
communication and conflict evaluation skills. O'Farrell and colleagues
combined couples therapy with the learning and rehearsal of a relapse
prevention plan. Among alcoholics with severe marital and drinking problems,
the combination approach produced improved marital relations and higher
abstinence rates through 30 months of follow-up compared with patients
undergoing only BMT.
Many persons with alcohol-related problems receive counseling from primary
care physicians or nursing staff in the context of five or fewer standard
office visits. Such treatment, known as brief intervention, generally
consists of straightforward information on the negative consequences of
alcohol consumption along with practical advice on strategies and community
resources to achieve moderation or abstinence. Two controlled trials in the
United States and Canada demonstrated that this approach reduced drinking,
alcohol-related problems, and patients' use of health care services. Most
brief interventions are designed to help those at risk for developing
alcohol-related problems to reduce their alcohol consumption.
Alcohol-dependent patients are encouraged to enter specialized treatment
with the goal of complete abstinence.
The brief intervention approach has also been successfully applied outside
the primary care setting. Evidence suggests that 25 to 40 percent of trauma
patients may be alcohol dependent. Gentilello and colleagues conducted a
randomized controlled study among patients in a trauma center who had
detectable blood alcohol levels at the time of admission. The researchers
found that a single motivational interview at or near the time of discharge
reduced drinking levels and re-admission for trauma during 6 months of
follow-up. Monti and colleagues conducted a similar randomized controlled
study among youth ages 18 to 19 admitted to an emergency room with
alcohol-related injuries. After 6 months, although all participants had
decreased their alcohol consumption, the group receiving brief intervention
had a significantly lower incidence of drinking and driving, traffic
violations, alcohol-related injuries, and alcohol-related problems.
Brief intervention among freshman college students previously identified as
being at high risk for harmful consequences of heavy drinking has been shown
to result in a significant decline in alcohol-related problems.
Treating Alcohol and Nicotine Addiction Together
Nicotine and alcohol interact in the brain, each drug possibly affecting
vulnerability to dependence on the other. Consequently, some researchers
postulate that treating both addictions simultaneously might be an
effective, even essential, way to help reduce dependence on both. A recent
study by Hurt and colleagues showed that treatment for nicotine dependence
did not interfere with abstinence from alcohol or other drugs. Furthermore,
such concurrent treatment not only enhanced cessation from smoking, it also
did not induce already abstinent smokers to relapse to drinking.
More recently, research has focused on the development of medications for
blocking alcohol-brain interactions that might promote alcoholism. In 1995
the U.S. Food and Drug Administration approved the use of the medication
naltrexone (ReViaTM) as an aid in preventing relapse among recovering
alcoholics who are simultaneously undergoing psychosocial therapy. This
approval was based largely on two randomized controlled studies that showed
decreased alcohol consumption for longer periods in naltrexone-treated
patients compared with those who received a placebo.
As is the case with all diseases, however, naltrexone is only effective if
taken on a regular basis. Like all medications, naltrexone has side effects.
One recent study reported a high rate of side effects, which probably
explains why this study, in contrast with most other studies, failed to find
Acamprosate showed promise in treating alcoholism in several randomized
controlled European trials involving more than 3,000 alcoholic subjects who
were also undergoing psychosocial treatment. Analysis of combined results
showed that more than twice as many alcoholics receiving acamprosate
remained abstinent up to 1 year compared with subjects receiving
psychosocial treatment alone.
Research suggests that some medications may be more effective for certain
types of alcoholics. For example, when ondansetron (Zofran®) was combined
with psychotherapy, alcoholics who had begun drinking heavily before age 25
(i.e., early-onset alcoholics) decreased their alcohol consumption and
increased their number of abstinent days, but later onset alcoholics did
not. Sertraline (Zoloft®), in contrast, appears to reduce drinking in
late-onset, but not early-onset, alcoholics. However, fluoxetine (Prozac®),
a medication related to sertraline, has not been found to be effective in
In conclusion, research supports the concept of using medications as an
adjunct to the psychosocial therapy of alcohol abuse and alcoholism.
However, additional clinical trials are required to identify those patients
most likely to benefit from such an approach, to determine the most
appropriate medications for different patient types, to establish optimal
dosages, and to develop strategies for enhancing patient compliance with
New Advances in Alcoholism Treatment-A Commentary by NIAAA Director Enoch
Alcoholism clinicians have access today to a wide range of treatment options
for their patients. Some of these treatments, such as 12-step self-help
programs, have been around a long time. Others-including brief intervention
and various therapies borrowed from other fields, such as motivational
enhancement therapy and couples therapy-are relatively new concepts that
have been shown to be effective in reducing the risk for alcohol-related
problems. The key change that has occurred, of course, is the advent of
alcoholism clinical research, which over the past 15 years or so has made
significant progress toward rigorous evaluation of both existing therapies
and newly developed therapies for use in treating alcohol-related problems.
Finally, continued research on alcohol's effects in the brain and on the
links between brain and behavior, which has already led to the development
of medications to reduce craving, is likely to provide clinicians with a
range of highly specific medications that will, when used in conjunction
with behavioral therapies, improve the chance for recovery-and the lives-of
those who suffer from alcohol abuse and dependence.
1Project MATCH is a national, multisite, randomized clinical trial that
produced data on the outcomes of specific alcoholism treatment approaches.
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