Sunday, October 5, 2014
The Best Treatment for Alcohol Use Disorder Your Addiction Counselor Isn’t Telling You
Pharmacological solutions for alcohol use disorder are often met with disdain, despite clinical studies supporting them as the most effective solutions by far.
Between the Harms Reduction community, the SMART Recovery® community, and Alcoholics Anonymous, pharmacology as a solution for alcohol use disorder is not viewed in a very positive light. Harms Reduction, by far the most tolerant of pharmacology solutions of any of the recovery movements, is still reluctant to utilize pharmaceutical options until after therapy has proven ineffective. Among these movements, Alcoholics Anonymous is the most intolerant towards medications. In fact, a survey conducted by the Journal of Alcohol Studies in 2000 found that out of a random sample of 277 members, 29% of them were directly pressured by AA members to go off their medication. The study also found that the more frequently Alcoholics Anonymous meetings were attended, the less likely AA members were to view medication as a positive treatment option.
Even the most modern of recovery movements ignore the benefits of pharmacological treatment due to their philosophical roots. Both Harms Reduction and SMART Recovery® are movements founded by psychologists who have rightfully observed through evidence-based medicine that alcohol use disorder can be treated with therapy alone. In fact, Cognitive-Behavioral Therapy and Motivational Interviewing are both proven to be effective treatments for alcohol use disorder. Relying on these techniques, Harms Reduction and SMART Recovery seem to question why they should use medication at all, when alcohol use disorder can be treated by therapy alone. Many in the psychology and addiction counseling community seem to have drawn the same conclusion.
Alcoholics Anonymous members have an even stranger approach to alcohol addiction treatment. Medical proponents of AA seem to push insistently for a disease concept of alcohol addiction. They are particularly interested in the idea that alcoholism is a genetic/neurological disorder. As a genetic disorder, AA distinguishes between the “real alcoholic” whose disease is incurable and a “hard drinker” who can recover with therapy. AA members use this distinction as comparison for justifying why therapy will not work but AA does. If “real alcoholism” is a genetic or neurological disease, then medical proponents of AA have a clear justification for not offering therapy, or offering therapy secondarily after 12-step therapy, or even in conjunction with 12-step therapy. Ironically, with the conclusion that alcoholism is a medical disease, AA medical proponents do not conclude that medical treatment should follow. Extreme AA proponents would argue that alcoholism is a spiritual disease, not a medical one. This view, of course, is not recognized in any medical literature. Medical professionals who are AA proponents are generally hesitant to espouse the belief that alcoholism is purely a “spiritual disease,” since such a position is not defensible under scientific scrutiny. So medical proponents of AA favor the disease concept of alcoholism; why then do they refuse to offer medical treatment to their patients?
As an epidemiologist, my mission is to determine the best course of action to treat a population. I am personally astounded by the recovery community’s general lack of epidemiological guidance when developing drug and alcohol treatment programs for public health. Oddly enough, drug and alcohol addiction is the one area of medicine in which epidemiologists do not spearhead the public treatment of a medical problem. The efficacy of drug treatment programs in America is low, embarrassingly low. In fact, the (conservatively estimated) $70 billion dollar treatment industry is lucky to demonstrate any efficacy at all. This has been the case since the emergence of the inpatient rehab in the 1980s, and since rehab treatment models have remained static since that time, recovery rates have not improved significantly either.
In comparison with epidemiological efforts to combat nicotine addiction, these results present a stark contrast. Abstinence rates for nicotine are at an all-time high of 82% in the United States according to the CDC. Epidemiological nicotine addiction treatment has been the only drug program to have significantly impacted drug use in a free society in recorded history. So what do epidemiologists do right that the drug rehabilitation industry is doing wrong?
The answer is pharmacological assistance in quitting addiction. Let me say it again: Medication is a vital key in helping a population quit addiction. Let’s look at nicotine addiction: it is very widely known and well accepted that nicotine is one of most addictive drugs ever encountered. Faced with such an addictive drug, how is it possible that epidemiologists were able to move the needle in smoking rates? The answer is that they embraced a medical-psycho-social model of recovery. Acomprehensive study from the Western Journal of Medicine in 2002 found that from over 6,000 articles on nicotine cessation, two conclusions emerged. The first was that taking FDA-approved medication for nicotine cessation more than doubled the likelihood of quitting smoking. The second conclusion was that this likelihood was increased even further by coupling anti-smoking medication with evidence-based therapy for behavioral modification.
Knowing that FDA-approved anti-addiction medication works for smoking, and that anti-addiction medication coupled with therapy works even better, one wonders why the FDA hasn’t approved medication for those with alcohol use disorder? In fact, they have, and these medications are very likely the ones that your counselor or sponsor is not telling you about. In fact, the majority of the rehabs in the United States do not use any of this medication. Neither therapy methods alone nor 12-steps alone work nearly as effectively as therapy plus medication. No study in existence shows therapy or 12-step involvement to be as effective as a combined therapy and medication program.
So what are these FDA approved medications and how effective are they? The FDA has approved two different medications for use with alcohol use disorder. The first is acamprosate (Campral is the brand name). Acamprosate has been in use since the 1980s for alcohol use disorder treatment in Europe and was accepted by the FDA in 2004. It functions in a number of ways to correct chronic drinking in the brain, but its primary function is to correct initial depression that alcoholics get when they first quit drinking and reduce cravings by inhibiting receptors that alcohol up-regulates. In layman’s terms, it calms the feelings of restlessness, irritability, and discontent that alcoholics experience when they first quit drinking. Acamprosate is meant to be taken daily for the first 12 months of abstinence.
The second medication is Naltrexone. Naltrexone is an opioid inhibitor that has been FDA approved as a constant low dose (daily intake) or as a supplement prior to drinking. If the goal is abstinence, this drug can serve two purposes. In chronic alcoholics, a constant low dose inhibitor may stop the immediate cravings for alcohol although long term use of daily intake, monthly injections, or implants may actually up-regulate the opioid system resulting in worse relapses after the patient is taken off the medication. Naltrexone is actually best served as an emergency relapse drug. Patients, prior to relapse, have taken this drug and report significantly lower impact of their relapse. In fact, naltrexone works so well to reduce relapse that many alcoholics use it to successfully drink on a regular basis with very few reports of high binge drinking. It is entirely possible that rather than going to AA meetings, the majority of alcoholics in the near future can simply carry a bottle of naltrexone with them for drinking occasions. Until that time, for those who want to be abstinent, naltrexone works as a great emergency relapse drug in combination with acamprosate.
Think of these drugs like asthma medications. Most asthma patients have a daily inhaler and an emergency inhaler. For people suffering from alcohol use disorder, acamprosate is the daily drug and naltrexone is the emergency relapse drug. Any program that does not prepare alcoholics to reduce the impact of relapse is simply unrealistic. Of those attempting life-long abstinence, over 99% will drink at least once within a 20-year period. It is an ethical responsibility of health practitioners to prepare those with alcohol use disorder for this reality and provide information about how to mitigate it when it occurs.
The combination of acamprosate plus naltrexone and cognitive-behavioral therapy currently shows the highest rates of recovery of any system in clinical trials. This combination has been studied thoroughly over the past decade with abstinence rates reaching higher than 65%. No other program, not Alcoholics Anonymous, nor SMART Recovery®, comes close to achieving these rates of abstinence, yet hardly any treatment program in the country is engaging in this practice. It’s time health practitioners abandon personal preferences and start asking what is optimal for treatment. Engaging in optimal treatment with pharmaceutical and therapy combinations should be the first protocol used by any alcohol rehabilitation program, and only if that fails should alternative or off-label treatments be used. In light of the overwhelming evidence of the combined pharmaceutical and therapy efficacy, the rehabilitation industry’s refusal to use this protocol is puzzling at best.
Matthew Leichter is a writer based in Baltimore, Maryland. He is a published healthcare statistican and epidemiologist currently pursuing a doctorate in epidemiology from Capella University and has worked as an epidemiologist for Humana, Blue Cross Blue Shield, IMS Health, Cognilytics, and Walgreens. He last wrote about how Obamacare is killing AA and why smart recovery will never replace AA.