Alcoholism comes in many forms. There is binge drinking, all so common among young adults; alcohol dependence, when the body reacts to reductions in blood alcohol levels with misery and sometimes (dangerous) withdrawal; and chronic alcoholism when this drug, which in moderate amounts is known to protect our health, is heavily ingested over many years and irrevocably destroys brain tissue and body organs like the liver, kidneys and heart.
Alcoholism is the third leading cause of preventable disease and death, after smoking and obesity. Each year over 80,000 people die of its complications and countless more suffer and create heartache and economic hardship for their families, communities and countries. There are many paths to recovery from alcoholism -- the most familiar being simple abstinence (foregoing any consumption on your own) and abstinence aided by 12-step programs (AA is the most well-known). While these paths deserve the respect they have earned there is one path that has not gained the recognition it merits; as a consequence too many people, and their families, go without the help that could lead to a better life with less of the ravages of this disease.
In recent years we have seen the use of a number of medications that have been scientifically shown to work. These medications, especially when added to counseling, significantly improve a person's chances of getting and staying sober. Yet medications are remarkably underutilized. Here we have an example where the pharmaceutical industry has not swayed how doctors prescribe or patients' consume their products.
Why are medications not commonly used in light of the ubiquity of alcoholism and its consequences? To begin with knowledge of these effective medications seems to not have been spread widely as it has with antidepressants, tranquilizers, asthma inhalers, statins and erectile enhancers. Moral views of alcoholism have been slow to die, as well, despite decades of evidence that it is a brain disease not a character weakness or failure of will. More troubling are the legions of old school alcohol counselors who may insist that any drug is a drug to be avoided (perhaps because they themselves gained recovery by abstinence and recovery programs before the advent of these agents) and often disdain a path assisted by medications, even if it might be more effective for some people.
Disulfiram (Antabuse™), where someone chooses to take a medication they know will make them horribly sick if they imbibe, has been around for ages. But that is not what we are talking about here. Instead we need to consider several medications that work by affecting specific brain centers related to pleasure, distress and mood, all which drive our behaviors. The primary agents available today changing the treatment of alcoholism are naloxone (Narcan™, Depade™, ReVia™ and Vivitrol™ -- the last works for a month and is given IM) and topimarate (Topamax™). Acamprosate (Campral™) showed good success in early studies but recent reports cast some doubt about its effectiveness though it bears mentioning.
Each of these agents works a bit differently. Which one to use is informed by whether someone has early manifestations of the disease or has progressed to dependence or chronic alcoholism. What you need to know is that these medications exist -- not necessarily which one (just as you need to know there are antibiotics for infection but not which one you need). One of these medications may help you or your loved one. naloxoneacts in the brain to reduce the pleasure and reinforcement produced by a drink; the effect is that a person is less apt to want to drink. Topiramate, a medication in use for seizure disorders, appears to reduce the craving for alcohol. Acamprosate is thought to work by reducing the symptoms of going dry, including anxiety and insomnia, features of withdrawal which can last for months. These are important interventions for people with the disease of alcoholism to consider, just as antidepressants are for serious depression, antihypertensives are for high blood pressure and statins are for high cholesterol.
But no pill is a magic bullet. Medications need to be combined with counseling. A type of counseling now proven to work is a brief (several sessions for some people more for others -- with ongoing monitoring and support) intervention focused on improving a person's motivation to get and stay sober. This form of counseling is termed motivational enhancement therapy (MET). Remarkably, MET is readily learned and can be practiced by primary care physicians, psychiatrists and other mental health professionals, substance use counselors and even emergency room medical staff. This means that many people can be effectively served (though not all) by medication and brief motivational counseling in general medical and mental health settings thereby greatly expanding access for those who have not turned (or may not) to traditional alcohol rehab programs. That is big news.
One word about depression and alcoholism, also now well-studied. People who show both conditions, and they commonly co-occur, do better when an antidepressant (e.g., a selective serotonin agent like sertraline {Zoloft™) is combined with one of the medications mentioned above, particularly naloxone. Medications combined with motivational enhancement and psychotherapy for depression is the optimal treatment plan when depression and alcoholism coexist.
Where can we start to advance the use of these effective medications? We can start by making screening for alcohol problems standard practice in primary care and mental health practices. We can start by using a simple screening tool, like the CAGE or AUDIT (both very brief questionnaires completed by the patient while in the waiting room that produce a score which can uncover the presence of the disease to the doctor). You can Google these screens, which are readily available at no cost on the Internet. Your doctor (or a trained clinician) then pursues the findings of the screen by asking a series of questions about drinking that can confirm the diagnosis, sometimes with various lab tests that may show the effects of the disease on the body. Screening and systematic questioning by a clinician for alcoholism is no different from screening for high blood pressure, diabetes or high cholesterol. Screening and treating these other medical conditions is now standard practice in primary care. Screening and brief intervention for alcoholism need to become standard practice as well -- in primary care as well as mental health settings.
When screening becomes standard practice for a disease, so does the delivery of its treatment. Physicians and other professionals learn to treat a condition when it is detected by a screening test and their examination makes the diagnosis. The treatment for alcoholism, a disease found so commonly in every type of medical and mental health setting, can be highly effective. It's time to get beyond ignorance of these medications, over moral judgments and now dated practice patterns to give people what they need, namely more effective and broader access to treatments for a condition that wrecks havoc with their lives and ours.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
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