New Advances in Alcoholism Treatment
More than 700,000 Americans receive alcoholism treatment on any given day (1). However, the techniques of
alcoholism therapy have traditionally been based on clinical experience and intuition, with little rigorous validation
of their effectiveness (2). 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 (3). 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 (4). 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 (5, 6), its efficacy has rarely been
assessed in randomized clinical trials (7).
One randomized study of patients entering employee assistance
programs compared inpatient treatment combined with AA with
referral to AA alone (8). This study found that inpatient treatment, a combination of professional treatment and
AA, will achieve better results for more people than AA alone (8). Ouimette and colleagues (9), 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 (9). Interpretation of these results is complicated by the nonrandom assignment of
patients to the different treatment types (9).
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 (4, 10). 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 consumption (4, 11).
Psychosocial Therapy
The following sections deal with selected recent approaches or considerations relevant to the psychosocial
treatment of alcohol-related problems.
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 (12, 13). 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 (14). In one
study (15), the motivational interviewing technique - a key component of MET - was shown to overcome patients'
reluctance to enter treatment more effectively than did conventional techniques.
Couples Therapy
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 (16).
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 (17). O'Farrell and colleagues (18) 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 (18, 19).
Brief Interventions
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 (20). 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 (21, 22). Two controlled trials
in the United States and Canada demonstrated that this approach reduced drinking (23, 24), alcohol-related
problems (24) and patients' use of health care services (23). 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 (21).
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 (25). Gentilello and colleagues
(26) 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 followup (26). Monti
and colleagues (27) 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 (27).
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 (28, 29).
Treating Alcohol and Nicotine Addiction Together
Nicotine and alcohol interact in the brain, each drug possibly affecting vulnerability to dependence on the other
(30). 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 (31)
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.
Pharmacotherapy
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 (ReVia
TM) 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
(32, 33).
As is the case with all diseases, however, naltrexone is only effective if
taken on a regular basis (34). 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 naltrexone effective (35).
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 (36).
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 (37). Sertraline (Zoloft
®), in contrast, appears to reduce
drinking in late-onset, but not early-onset, alcoholics (38). However, fluoxetine (Prozac
®), a medication related to
sertraline, has not been found to be effective in late-onset alcoholism (39).
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 medication regimens.
New Advances in Alcoholism Treatment - A Commentary by NIAAA Director Enoch Gordis, M.D.
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.
1 Project MATCH is a national, multisite, randomized clinical trial that produced data on the outcomes of specific
alcoholism treatment approaches.
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