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Pharmacological and Nonpharmacological Treatment of Alcohol Dependence


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Title: Pharmacological and Nonpharmacological Treatment of Alcohol Dependence

Pharmacological and Nonpharmacological Treatment
of Alcohol Dependence
  • Sponsored by
  • American Society of Addiction Medicine (ASAM)
  • Supported by
  • Florida Society of Addiction Medicine (FSAM)
  • Southern Coast Addiction Technology Transfer
    Center (SCATTC)

Jeffrey D. Kamlet, MD Private Practice, Internal
Medicine Forensic, Addiction, and Bariatric
Medicine Adjunct Professor of Medicine School of
Graduate Health Sciences Barry University Miami,
Florida Vineet Mehta, MD President Center for
Non-Addictive Living Attending Physician Circles
of Care Private Practice, Psychiatry and
Addiction Psychiatry Melbourne, Florida
ASAM Disclosure of Relevant Financial
Relationships Content of Activity
Pharmacological and Nonpharmacological Treatment
of Alcohol Dependence 2006 Courses
Glossary of Terms
  • Commercial Interest - ACCME defines a commercial
    interest as any proprietary entity producing
    healthcare goods or services, with the exemption
    of nonprofit or government organizations and
    non-healthcarerelated companies.
  • Financial relationships - Financial relationships
    are those relationships in which the individual
    benefits by receiving a salary, royalty,
    intellectual property rights, consulting fee,
    honoraria, ownership interest (eg, stocks, stock
    options or other ownership interest, excluding
    diversified mutual funds), or other financial
    benefit. Financial benefits are usually
    associated with roles such as employment,
    management position, independent contractor
    (including contracted research), consulting,
    speaking and teaching, membership on advisory
    committees or review panels, board membership,
    and other activities from which remuneration is
    received, or expected. ACCME considers
    relationships of the person involved in the CME
    activity to include financial relationships of a
    spouse or partner.
  • Relevant financial relationships - ACCME focuses
    on financial relationships with commercial
    interests in the 12-month period preceding the
    time that the individual is being asked to assume
    a role controlling content of the CME activity.
    ACCME has not set a minimal dollar amount for
    relationships to be significant. Inherent in any
    amount is the incentive to maintain or increase
    the value of the relationship. ACCME defines
    relevant financial relationships as financial
    relationships in any amount occurring within the
    past 12 months that create a conflict of
  • Conflict of Interest - Circumstances create a
    conflict of interest when an individual has an
    opportunity to affect CME content about products
    or services of a commercial interest with which
    he/she has a financial relationship.

Supported by
  • Supported by an unrestricted educational grant
    from Forest Pharmaceuticals, Inc.

Meeting Agenda
  • 100 PM 110 PM Introductions/Welcome
  • FSAM State Chapter President and Faculty
  • 110 PM 315 PM Presentations
  • (Each presentation consists of a lecture and Q
    A session)
  • Module 1 Effective Treatment for Alcohol
  • Dependence Pharmacotherapy Options
  • Module 2 Effective Treatment for Alcohol
  • Dependence Integrating Evidence-Based Behavioral
    Interventions and Treatments and Psychosocial
    Support Services With Pharmacotherapy
  • Module 3 Concomitant Conditions Psychiatric,
    Medical, and Other Substance Use
  • 315 PM 330 PM BREAK
  • 330 PM 500 PM ASAM/NAADAC Panel Discussion
    Strengthening Physician/Counselor Relationships
    for Improved Patient Outcomes in the Treatment of
    Alcohol Dependence
  • 500 PM 515 PM Evaluation and Adjournment

To Receive Credit
  • Complete and return the survey and program
    evaluation form to Denise Petrone
  • Before leaving, please sign the registration card
  • ASAM will mail you your certificate

Effective Treatment for Alcohol Dependence
Pharmacotherapy Options Module 1
Program Objectives
  • At the conclusion of this activity, participants
    should be able to
  • Review clinically relevant developments and
    research in the use of disulfiram, naltrexone,
    and acamprosate for alcohol dependence disorder
  • Identify and discuss clinical issues relative to
    the use of pharmacotherapy
  • Review and discuss existing and promising
    treatment and management options for alcohol
  • Discuss evidence-based behavioral intervention
    and treatment, which includes integration of
    psychosocial support services with
  • Review relevant clinical information on
    concomitant conditions

Module 1 Overview
  • The scope of the problem
  • Alcoholism is a brain disease
  • Pharmacotherapy for alcohol dependence
  • Pharmacotherapy in practice

Prevalence of Alcohol Use
NIAAA National Epidemiologic Survey onAlcohol
and Related Conditions (NESARC)
Any Alcohol Disorder 17.6 million (8.5)
Alcohol Dependence 7.9 million (3.8)
Alcohol Abuse 9.7 million (4.7)
NIAAANational Institute on Alcohol Abuse and
Alcoholism. Grant BF et al (2004).
  • Eight million adult United States citizens are
    dependent on alcohol
  • Alcoholism tends to run in families and affects
  • More than 50 of American adults have a past
    history or close relationship with alcoholism
  • 25 of minors have been exposed to familial
    alcoholism or alcohol abuse
  • Alcohol use is implicated in approximately 25
    of violent crimes and more than 16,000 fatal car
    accidents each year
  • National alcoholism costs are approximately 185
    billion each year

Individuals younger than 18 years of age.
Societal Costs of Alcohol Dependence
Total Cost 184.6 Billion
7,466 (4)
24,093 (13)
15,963 (9)
10,085 (5)
2,909 (2)
1,253 (1)
36,499 (20)
86,368 (47)
Cost in millions of US dollars. FASfetal
alcohol syndrome. Key definitions correspond to
pie chart sections in clockwise order beginning
specialty alcohol services at the 12 oclock
Harwood H et al. In NIH Publication No. 98-4327.
Available at http//
Addiction A Brain Disease
  • Neurological adaptation
  • Mesolimbic DA system
  • Animal studies
  • Human studies

Brain Reward Pathways
  • The VTA-nucleus accumbens pathway is
    activated by all drugs of dependence, including
  • This pathway is important not only in drug
    dependence, but also in essential physiological
    behaviors such as eating, drinking, sleeping, and

Messing RO (2001).
Relapse and Conditioning
  • Repeated use of alcohol has caused conditioning
    to occur in related circuits
  • Now cues associated with alcohol use can
    activate the reward and withdrawal circuit
  • This circuit can evoke anticipation of alcohol or
    feelings similar to withdrawal, which may
    precipitate relapse in an abstinent patient

Messing RO (2001).
Overview of Major Neurotransmitters Associated
With Alcohol
  • General Function Regulates motivation,
    reinforcement, and fine motor control
  • Specific Action by Alcohol Initiates a release
    at the NAC either directly or from projections
    via the mesolimbic system from the VTA
  • Alcohol-Related Function Mediates motivation and
    reinforcement of alcohol consumption
  • NACnucleus acumbens VTAventral tegmental area.

Swift RM (1999).
?-aminobutyric Acid (GABA)
  • General Function Serves as the primary
    inhibitory neurotransmitter in the brain
  • Specific Action by Alcohol Causes tonic
    inhibition of dopaminergic projections to the
    VTA and NAC. Prolonged alcohol use causes a
    down-regulation of these receptors and a
    potential for decreased inhibitory
  • Alcohol-Related Function May contribute to
    intoxication and sedation inhibition of GABA
    function following drinking may contribute to
    acute withdrawal symptoms

Swift RM (1999).
  • General Function Serves as the major excitatory
    neurotransmitter in the brain
  • Specific Action by Alcohol Alcohol inhibits
    excitatory neurotransmission by inhibiting both
    NMDA and non-NMDA (kainite and AMPA) receptors.
    Up-regulation of these receptors to compensate
    for alcohols antagonistic effect occurs after
    prolonged exposure to alcohol, resulting in an
    increase in neuroexcitation
  • Alcohol-Related Function May contribute to acute
    withdrawal symptoms inhibition of glutamate
    function following drinking cessation may
    contribute to intoxication and sedation
  • NMDAN-methyl-D-aspartate AMPAa-amino-3-hydroxy-
    5-methisoxizole-4-propionic acid.

Swift RM (1999).
Opioid Peptides
  • General Function Regulates various functions and
    produces morphine-like effects, including pain
    relief and mood elevation
  • Specific Action by Alcohol Alcohol stimulates
    ß-endorphin release in both the NAC and VTA
    area. ß-endorphin pathways can lead to increased
    dopamine release in the NAC
  • Alcohol-Related Function Contributes to
    reinforcement of alcohol consumption, possibly
    through interaction with dopamine

Swift RM (1999).
Alcohol Dependence Is A Chronic Disease
Similar Outcomes to OtherChronic Illnesses
  • Type 1 DM 30 to 50 relapse each year
    requiring additional medical care
  • HTN and asthma 50 to 70 relapse each year
    requiring additional medical care
  • Addiction 40 to 60 relapse within first year

DMdiabetes mellitus HTNhypertension. McLellan
AT et al (2000).
  • Less than 30 of patients with type 1 DM, HTN,
    and asthma adhere to prescribed diet and
    behavioral changes designed to improve function
    and reduce risk factors.

McLellan AT et al (2000).
Defining Alcohol Use
Defining the Standard Drink
  • A standard drink 14 g ethanol
  • 12 oz of regular beer or cooler (5 alcohol)
  • 5 oz of table wine (12 alcohol)
  • 1.5 oz of hard liquor (40 alcohol, 80 proof)
  • The average person metabolizes about 1 standard
    drink per hour

NIAAA. Helping Patients Who Drink too Much a
Clinicians Guide NIAAA Web site.
US Government Recommended Safe Levels of
Alcohol Consumption
  • Men 2 drinks per day
  • Women 1 drink per day

At-Risk Drinking
  • 3 out of 10 US adults consume alcohol at levels
    that increase their risk for physical, mental
    health, and social problems
  • Of those at risk, about 25 currently have
    alcohol abuse or dependence

NIAAA. Helping Patients Who Drink too Much a
Clinicians Guide NIAAA Web site.
At-Risk Drinking (Contd)
  • Defined as drinking at a level that causes or
    elevates the risk for alcohol-related problems
    or complicates the management of other health
  • Men
  • 5 or more standard drinks per day
  • 15 or more standard drinks per week
  • Women
  • 4 or more standard drinks per day
  • 8 or more standard drinks per week

Dawson DA et al (2005). NIAAA. Helping
Patients Who Drink too Much a Clinicians Guide
NIAAA Web site. http//

Alcohol Abuse
  • DSM-IV-TR Criteria
  • Maladaptive pattern of alcohol use leading to
    clinically significant impairment or distress,
    manifested within a 12-month period by at least
    1 of the following
  • Failure to fulfill role obligations at work,
    school, or home
  • Recurrent use in hazardous situations
  • Legal problems related to alcohol
  • Continued use despite alcohol-related socialor
    interpersonal problems

DSM-IV-TRDiagnostic and Statistical Manual of
Mental Disorders, 4th edition, text
revision. American Psychiatric Association. In
DSM-IV-TR. 2000.
Alcohol Dependence
  • DSM-IV-TR Criteria
  • Maladaptive pattern of alcohol use leading to
    clinicallysignificant impairment or distress,
    manifested within a12-month period by at least 3
    of the following
  • Tolerance
  • Withdrawal
  • Loss of control over amount of alcohol consumed
  • Preoccupation with controlling drinking
  • Preoccupation with drinking activities
  • Impairment of social, occupational, or
    recreational activities
  • Use is continued despite persistent problems
    related to drinking

American Psychiatric Association. In DSM-IV-TR.
Pharmacologic Treatment of Alcohol Dependence
Treatment Overview
  • Psychosocial treatments help many alcoholics
    reduce their drinking or achieve abstinence
  • 40 to 70 relapse within a year
  • Neuroscientific advances suggest the possibility
    of developing medications to enhance the
    effectiveness of psychosocial treatments
  • These medications target neurotransmitter systems
    that mediate alcohol reward associated with its
    abuse liability and/or ameliorate neurochemical
    dysfunction in those with a biological
    predisposition to the disease

Litten RZ et al (1996). Swift RM (1999).
Neuropharmacological Targets for Treating Alcohol
  • Neurotransmitters and receptors
  • Acetylcholine
  • Adenosine (A1, A2 receptors)
  • Cannabinoid receptors
  • DA (D1, D2, D3, D4)
  • GABAA, GABAB receptors
  • Glutamate (NMDA, AMPA, kainate receptors)
  • Glycine
  • Norepinephrine (NE alpha a, beta ß
  • Opioid peptides (mu µ, delta ?, kappa ?
  • Other peptides (vasopressin, neuropeptide Y)
  • Serotonin (5-HT several receptors, particularly
  • Neurotransmitter transporters
  • Adenosine, DA, 5-HT, NE
  • Voltage-gated ion channels
  • L-type, N-type calcium channels sodium channels
  • Second messengers
  • G-proteins, phospholipases, protein kinases,
    neurosteroids, hormones

Anton RF et al (2003). Litten RZ et al (2005).
Current Neuropharmacological Strategies to Reduce
Drinking Behavior
  • Medications that reduce alcohol seeking or urge
    to drink (craving)
  • Opioid antagonists, ondansetron, topiramate
  • Medications that reduce the dysphoria and other
    symptoms of acute and protracted withdrawal
  • Acamprosate, sedatives (?-hydroxybutyrate),
    baclofen, antiepileptics/mood stabilizers
    (carbamazepine, valproate, topiramate)
  • Medications that reduce impulsivity/attention
  • DA agonists and antagonists, 5-HT antagonists
  • Medications that reduce alcohol bioavailability
  • Kudzu/bioflavonoids, a2-antagonists
  • Medications that increase satiety/reduce
    appetitive drive
  • Naltrexone, topiramate, cannabinoid (CB1)
    antagonists (?)
  • Medications that treat comorbid psychiatric
    illnesses or reduce psychological distress
  • Antidepressants (tricyclics, SSRIs),
    antipsychotics (typical and atypical),
    anxiolytics (buspirone)

SSRIsselective serotonin reuptake inhibitors.
Anton RF et al (2003).
Disulfiram Blocks Alcohol Metabolism
  • Ethanol
  • ? ? alcohol dehydrogenase
  • Acetaldehyde
  • ? ? aldehyde dehydrogenase
    (blocked by Antabuse)
  • Acetate (Acetyle co-enzyme A)
  • ?
  • Carbon dioxide and water

Opioid Antagonists Basic Science
  • Alcohol consumption affects the production,
    release, and activity of opioid peptides1
  • Opioid peptides mediate some of alcohols
    rewarding effects by enhancing midbrain DA
  • Opioid antagonists suppress alcohol-induced
    reward2 and general consummatory behaviors3
  • Genetic high-risk/FH individuals have an
    exaggerated alcohol-induced rise in ?-endorphin
    level, and are more responsive to naltrexone

FHpositive family history. 1. Herz A (1997).
2. Swift RM (1999). 3. Boyle AE et al (1998). 4.
Giannoulakis C (1996). 5. King AC et al (1997).
Opioid Antagonist Naltrexone Clinical Science
  • Some studies in alcoholics have found either no
    efficacy for naltrexone1 or efficacy among only a
    subgroup with medication compliance rates of 80
    to 902,3
  • Adverse events, particularly nausea, can result
    in up to 15 of withdrawals from clinical
    studies,4 and may limit acceptability in generic
    or managed care facilities
  • Depot naltrexone preparations may enhance
    compliance, and one study has demonstrated
    efficacy at reducing heavy drinking in men5
  • Targeted naltrexone might be another useful
    strategy to maximize compliance while diminishing
    adverse events rates6,7

1. Kranzler HR et al (2000). 2. Volpicelli JR et
al (1997). 3. Litten et al (1998). 4. Croop RS
et al (1997). 5. Garbutt JC et al (2005). 6.
Heinala P et al (2001). 7. Kranzler HR et al
Opioid Antagonist Naltrexone Clinical Science
  • Naltrexone 100 mg/day appears more efficacious
    than the usual 50 mg/day dose1,2
  • Identification of the alcoholic subgroup (perhaps
    those with a biological disease predisposition)
    most responsive to naltrexone is an important
    scientific goal3
  • Current evidence suggests that high craving and
    strong FH are strong predictors of a positive
  • Preliminary evidence suggests that allelic
    variation at the mu opioid receptor gene is
    associated with differential treatment response
    to naltrexone5

1. McCaul ME et al (2000). 2. McCaul ME et al
(2000). 3. Johnson BA and Ait-Daoud (2000). 4.
Monterosso JR et al (2001). 5. Oslin DW et al
Glutamate Antagonist Acamprosate Basic Science
  • Excitatory neurotransmitter N-methyl-D-aspartate
    (NMDA) contributes to alcohols intoxicating,
    cognitive, and dependence-forming effects
  • NMDA antagonist acamprosate reduces the intensity
    of post-cessation alcohol craving on exposure to
    high-risk drinking situations

Embellished from Spanagel and Zieglgansberger
Spanagel and Zieglgansberger (1997).
Glutamate Antagonist Acamprosate Clinical
  • Poorly absorbed, with a bioavailability of
    approximately 10
  • Excreted unmetabolized therefore, no risk of
    hepatotoxicity or interaction with alcohol
  • Should be used with caution in individuals with
    renal impairment
  • Relatively safe, the most common adverse event
    is diarrhea

CAMPRAL (acamprosate calcium) delayed-release
tablets prescribing information 2004.Mason et
al (2002).
Glutamate Antagonist Acamprosate Clinical
Science (Contd)
  • Approved for the treatment of alcohol dependence
    in 29 countries and in the US in July 2004
  • Methodological rigor was enhanced in later
    studies (e.g., Sass and colleagues1 Whitworth
    and colleagues2) by standardization of diagnosing
    alcoholism, laboratory measurements, and
    psychosocial treatment regimen
  • Although more than 20 clinical trials have been
    conducted, a meta-analysis of 17 positive studies
    revealed that acamprosate vs. placebo increased
    continuous abstinence rates following 3 (46 vs.
    34), 6 (36 vs. 23), and 12 (27 vs. 13)
    months of treatment3
  • Acamprosate also decreases frequency of drinking
    and the intensity of a relapse if drinking is
    reinstated after abstinence4,5
  • Predicators of treatment response that have been
    examined and found to have NO predictive value
    include increased levels of anxiety,
    physiological dependence, FH-, late age of onset,
    and being female6
  • For a review, see Johnson and Ait-Daoud (2000)7,
    Ait-Daoud and Johnson (2003)8, and Litten et al

1. Sass et al (1996). 2. Whitworth et al (1996).
3. Mann et al. (2004). 4. Chick and Lehert
(2003). 5. Tempesta et al (2000). 6. Verheul et
al (2005). 7. Johnson and Ait-Daoud (2000). 8.
Ait-Daoud and Johnson (2003). 9. Litten et al
Rationale for Combining Medications
  • Small to moderate effect sizes for single
  • Additive or synergistic effects to interact at
    multiple neuronal systems
  • Single medications might be effective at only
    particular phases of the illness
  • Combinations target a wider range of alcohol
    subtypes, particularly if there is a differential
    genomic environmental response
  • BUT
  • Potential for increased adverse events
  • Potential for lack of effect or unexpected
    antagonistic actions

Combined Medications for Treating Alcoholism in
the Clinic Acamprosate Plus Naltrexone
  • To determine the relative efficacy of naltrexone
    (50 mg/day) and acamprosate (1998 mg/day) both
    alone and in combination
  • 2 2 factorial with 40 men and women per cell
  • Double-blind placebo-controlled study
  • Psychotherapy weekly group coping-skills therapy
  • 12-week study duration

Kiefer et al (2003).
Comparing and Combining Naltrexone and
Acamprosate in Relapse Prevention of Alcoholism
Naltrexone Plus AcamprosateNaltrexoneAcamprosate
Proportion of Survivors (Nonrelapse)
Time, d
Kiefer et al (2003).
Medications Currently Approved for Alcohol
  • Disulfiram (Antabuse)
  • Naltrexone (ReVia)
  • Acamprosate (Campral)

Antabuse Florham Park, NJ Odyssey
Pharmaceuticals, Inc. Campral St. Louis, Mo
Forest Pharmaceuticals, Inc. ReVia Wilmington,
De DuPont Pharmaceuticals.
Disulfiram (Antabuse)
Antabuse Florham Park, NJ Odyssey
Pharmaceuticals, Inc.
Naltrexone (ReVia)
ReVia Wilmington, De DuPont Pharmaceuticals.
Acamprosate (Campral)
CrClcreatinine clearance.
Campral St. Louis, Mo Forest Pharmaceuticals,
Is the Primary Care Office Appropriate for
  • Willingness and knowledge of primary care
  • Stage of change (see Module 2) and willingness
    of patient
  • Severity and chronicity of alcohol use disorder
    (ASAM criteria)
  • Psychosocial support available within family and
  • Prior treatment response
  • Availability of psychosocial and behavioral
  • Adherence to treatment plan

Monitoring Pharmacotherapy for Alcohol Dependence
  • Watch for evidence of alcohol and drug use
  • Ask about alcohol and drug use
  • Consider blood and urine testing (alcohol and
    drug screens, biologic indicators-transaminase
  • Evaluate adherence to medication and all aspects
    of treatment plan
  • Monitor Alcoholics Anonymous or other group
  • Involve other care givers
  • Evaluate for ongoing psychiatric illness
  • Evaluate other stressors
  • Monitor side effects
  • Provide support

Patient Selection for Pharmacotherapy
  • Research has yet to fully define subtypes of
    patients with alcohol dependence who respond to
  • Naltrexone may be best for those with a FH of
    alcohol dependence and significant craving
  • Medication is only useful for patients who are
    interested in treating their alcohol abuse or
  • Some physicians provide pharmacotherapy to all
    their patients with alcohol abuse and dependence,
    whereas other physicians have not yet used these
  • Medication adherence is a significant problem
  • Pharmacotherapy may not be effective in limiting
    other substance use

  • Alcohol dependence is a brain disease
  • Alcohol dependence is a chronic disease
  • Naltrexone, acamprosate, and disulfiram are
    effective in limiting alcohol use
  • Alcohol dependence can be addressed with
    pharmacotherapy in a primary care office
  • When integrated with psychosocial and behavioral

Effective Treatment for Alcohol Dependence
Integrating Evidence-Based Behavioral
Interventions and Treatments and Psychosocial
Support Services With Pharmacotherapy
  • Module 2

Introduction Module 2
  • Screening
  • Brief interventions
  • Evidence-based psychosocial and behavioral
    treatment approaches
  • Project MATCH
  • Alcoholics Anonymous (AA)
  • Integration of pharmacotherapy and

MATCHmatching alcoholism treatments to client
Clinical Indications for Screening
  • Key opportunities include
  • As part of a routine examination
  • Before prescribing a medication that interacts
    with alcohol
  • In the emergency department or urgent care center
  • In response to family member concerns

Clinical Indications for Screening (Contd)
  • In patients who
  • Are pregnant or trying to conceive
  • Are likely to drink heavily, such as smokers,
    adolescents, and young adults
  • Have health problems that might be
    alcohol-induced, such as cardiac arrhythmia,
    dyspepsia, liver disease, depression or anxiety,
    insomnia, and trauma
  • Have a chronic illness not responding to
    treatment as expected, such as chronic pain,
    diabetes, gastrointestinal disorders, depression,
    heart disease, and hypertension
  • A patient with signs of an emerging problem

Purpose of Screening
  • To determine if there are indicators of an
    alcohol problem requiring further assessment and
    perhaps clinical intervention

Step 1 Ask About Alcohol UseHelping Patients
Who Drink Too Much NIAAA 2005
Prescreen Do you sometimes drink alcoholic
Screening Complete
Ask the screening question about heavy
drinking days How many times in the past year
have you had 5 or more drinks in a day? (for
men) 4 or more drinks in a day? (for women)
Is screening positive? 1 or more heavy drinking
days or AUDIT score of gt5 for men or gt4 for women
  • Your patient needs additional evaluation. For a
  • more complete picture of the drinking pattern,
  • determine the weekly average
  • On average, how may days a week do you have an
    alcoholic drink?
  • On a typical drinking day, how many drinks do you
  • Record heavy drinking days in the past year and
  • weekly average in chart
  • Advise staying within maximum drinking limits
  • For healthy men up to age 65
  • No more than 4 drinks in a day AND
  • No more than 14 drinks in a week
  • For healthy women (and healthy men over age 65)
  • No more than 3 drinks in a day AND
  • No more than 7 drinks in a week
  • Recommend lower limits or abstinence as medically
    indicated, for example, for patients who
  • Take medications that interact with alcohol
  • Have a health condition exacerbated by alcohol
  • Are pregnant (advise abstinence)
  • Express openness to talking about alcohol use and
    any concerns it may raise
  • Rescreen annually

Assess for alcohol abuse or dependence
Please refer to NIAAA Clinicians Guide for
Interview Version form.
AUDITalcohol use disorders identification test.
Brief Interventions
  • Empirically based
  • Utilized by general medical and MH practitioners
  • For patients not needing, wanting, or ready to
    accept specialty care
  • Brief, structured, time limited, and directed
    toward a specific goal
  • Goal may be for the patient to try abstinence,
    moderation, or harm reduction
  • Approach is client centered, empathetic,
    engaging, noncoercive, and flexible

Brief Interventions (Contd)
  • Intended mainly for less severe and nondependent
    drinkers or those in early stages
  • Applied in a broad array of settings outside
    traditional treatment programs such as
    office-based practices and other nonspecialized
    treatment settings
  • Effective and cost effective

What We Know About Brief Intervention
  • Decreases alcohol use in both men and women
  • Decreases healthcare utilization
  • Decreases costs
  • 1 to 4 sessions are effective
  • Physicians can be trained to conduct brief

(No Transcript)
Goals of Brief Intervention
  • Reduce risk of harm from continued substance use
  • Abstinence provides the greatest degree of harm
    reduction and safety, but the specific goal for
    each individual is determined by consumption
    patterns, consequences, risks, and, above all,
    individual choice
  • Only the client can choose the goal, no matter
    what you recommend and think is best!

Appropriate Patients for Office-Based Physician
  • Patients with low to moderately severe
    alcohol/drug problems
  • Patients with more severe problems who are not
    ready to take action and/or accept referral for
    specialist consultation or treatment
  • Patients determined to try to reduce/stop on
    their own with minimal guidance before
    considering other treatment options
  • Intended mainly for less severe and nondependent
    drinkers or those in early stages
  • Applied in a broad array of settings outside
    traditional treatment programs such as
    office-based practices and other nonspecialized
    treatment settings

Physicians Stance
  • Be friendly and nonthreatening
  • Convey an attitude of curiosity and concern
  • Avoid being authoritarian or judgmental
  • Reassure that all information is confidential

Provide Objective Feedback
  • State your findings clearly, empathetically, and
  • Stick to the facts about the nature/severity of
    problem and its consequences without drawing
    firm conclusions
  • Draw connection between substance use and other
    health problems/risks, wherever possible
  • State your medical concerns

Inform Patients About...
  • Safe consumption limits for alcohol
  • Definitions of substance ABUSE and DEPENDENCY
  • Added risks posed by family history of alcohol or
    drug problems
  • Your confidence in their ability to change
  • Your willingness to help

Advise Patient to ABSTAIN if
  • Evidence of substance abuse or dependence
  • Pregnant or trying to conceive
  • Contraindicated medical/psychiatric condition or
  • Significant family history of alcohol/drug
    problems (at least 1 parent, grandparent, or

Advise Patient to CUT DOWN if
  • Drinking above low-risk levels without current
    evidence or prior history of alcohol dependence
  • Initial recommendation to abstain from
    alcohol/drugs has been rejected

Stages of Change
  • People with alcohol/drug problems generally fall
    into 1 of 5 stages along a continuum of readiness
    to change
  • This provides a useful framework for determining
    how best to approach patients in each stage of
    change and what types of interventions are most
    likely to be effective

Stages of Change (Contd)
  • Precontemplation Patient does not see the
    behavior as a problem, no desire to change (in
  • Contemplation Patient beginning to see the
    behavior as a problem, but still wavering
    (sitting on the fence) yes, but
  • Preparation Patient is considering options for
  • Action Patient taking specific steps to change
  • Maintenance Patient preventing relapse

The Wheel of Change
Assessing Patients Readiness to Change
  • Response to your feedback and advice offers
    strong clues about the patients readiness to
  • ASK What are your thoughts about these findings?
  • ASK To what extent do you view your drinking as
    a problem?
  • ASK Do you see a need for change?

Responding to Patient Resistance
  • Be prepared for a range of patient reactions,
    including shame, dismay, or anger
  • Avoid reacting to patient resistance as a
    challenge to your medical authority
  • Avoid getting into arguments or debates about how
    much drinking is too much
  • Avoid using the label addict or alcoholic
  • Emphasize to the patient that only he or she can
    make the decision to change

Willing to Consider Changing Your Drinking?
  • If NO, then
  • Restate your concerns
  • Encourage reflection of pros and cons of change
    versus no change
  • What are the barriers to change?
  • Reaffirm your willingness to help when the
    patient is ready and, at the very least, to
    reevaluate at a later time

If Patient Is NOT Willing to Consider Change
  • Do not react to patient resistance as a challenge
    to your medical judgment or authority
  • Avoid getting into arguments or debates about how
    much drinking is too much
  • Avoid using the label addict or alcoholic
  • Emphasize to patients that only they can make the
    decision to change you have no desire to
    pressure them to change
  • Agree to disagree restate your concerns about
    need for change
  • Your primary goal is to maintain an ongoing
    dialogue about their alcohol use and to continue
    to encourage change

Willing to Consider Changing Your Drinking?
  • If YES, then
  • Negotiate a Plan of Action based on
  • Problem severity
  • Stage of readiness to change
  • Level of involvement you, as the primary care
    physician, are willing and/or able to provide
  • Community resources for alcohol dependence

Substance Abuse Treatment Options
  • Medical detoxification
  • Inpatient
  • Outpatient
  • Residential treatment
  • Outpatient treatment
  • Office-based treatment
  • Addiction psychologist or psychiatrist
  • Addiction medicine specialist
  • AA or other self-help program

Scientifically Based Approaches to Addiction
  • Cognitive-behavioral therapy
  • Community reinforcement
  • Motivational enhancement therapy
  • 12-step facilitation
  • Contingency management
  • Pharmacologic therapies
  • Systems treatment
  • Behavioral couples therapy
  • Multidimensional family therapy

National Institute on Drug Abuse (1999). Onken
L (2002).
Alcoholics Anonymous
  • More people use AA than any other resource to
    address problems with alcohol.
  • McCrady Miller (1993)
  • Weisner, Greenfield, Room (1995)

McCrady Miller (1993). Weisner C et al (1995).
12-Step Programs
  • Accessible
  • Inclusive
  • Adaptable/diverse
  • Growing
  • Inexpensive
  • Successful

Estimated AA Membership (January 2004)
  • Members in United States 1,187,168
  • Groups in United States 52,735
  • Members Worldwide 2,066,851
  • Groups Worldwide 104,589
  • (AA is found in over 150 countries)

AA. Available at http//
Efficacy of AA
Timko C et al (2000).
AA Activities That Positively Correlated to
Drinking Outcomes
  • Having a sponsor
  • Engaging in 12-step work
  • Leading a meeting
  • Increasing ones degree of participation in the
    organization compared to a previous time
  • Sponsoring other AA members
  • Working the last 7 of 12 steps

Integration Is Necessary
  • Pharmacotherapy for alcohol dependence should
    always be accompanied by psychosocial and/or
    behavioral treatments

  • Monitor abstinence and adherence to treatment
  • Support abstinence, pharmacotherapy, and
    psychosocial/behavioral treatment
  • Discuss medication as it fits with recovery,
    psychotherapy, and AA
  • Involve other caregivers
  • Ongoing evaluation of appropriate level of care
  • Evaluate for ongoing psychiatric illness
  • Evaluate other stressors
  • Provide support

  • Screening should be done in all primary care
  • Brief interventions are effective
  • Many psychosocial and behavioral treatmentsare
  • Integration of pharmacotherapy and
    nonpharmacotherapy is necessary

Concomitant Conditions Psychiatric, Medical,
and Other Substance Use
  • Module 3

Medical Comorbidities
Some Early Clues to Problem Drinking
  • Injuries
  • Infections
  • Gastritis and duodenitis
  • Hematologic effects
  • Early hepatic markers

As Alcoholism Progresses, the Clinician Will Also
  • Hepatic effects
  • Cardiac effects
  • Pancreatic effects
  • Nervous system effects
  • Mental health effects
  • Cancer

Psychiatric Comorbidities
Initial Evaluation and Treatment of Psychiatric
  • In those with active substance use, the following
    must be taken into account
  • Psychiatric symptoms associated with substance
    use and withdrawal
  • Consequences of substance use
  • Substance induced psychiatric disorders
  • Withdrawal syndromes
  • Overlapping symptoms, enmeshed course

High Rates of Psychiatric Comorbidity in Alcohol
  • 78 of male alcoholics have a coexisting lifetime
    history of a psychiatric disorder
  • 86 of female alcoholics have a coexisting
    lifetime history of a psychiatric disorder

Kessler RC et al (1997).
ECA Data
Lifetime Prevalence ()
ECAepidemiologic catchment area.
ECA Data (Contd)
  • Patients with a psychiatric disorder
  • 22 also had an alcohol disorder
  • 15 also has a drug disorder
  • Patients with an alcohol disorder
  • 37 had a psychiatric disorder
  • Patients with a drug disorder
  • 53 had a psychiatric disorder

Lifetime Prevalence ofAlcohol Use
Abuse/dependence. BDIbipolar disorder type I
BDIIbipolar disorder type II DYSdysthymia
GPgeneral population MDmajor depression
OCDobsessive compulsive disorder PDpanic
disorder SZschizophrenia. Regler DA et al
  • Diagnosis difficult due to symptom overlap and
    enmeshed course
  • Account for substance-induced psychiatric
    disorder and withdrawal associated symptoms
  • History of psychiatric illness
  • Onset
  • Periods of abstinence
  • Family history
  • Prior treatment
  • Denial, inadequate history
  • Relapse
  • May require multiple visits

Treatment Guidelines
  • Nonaddicting medications, if possible
  • Educate about addiction and psychiatric illness
  • Account for complex feelings, attitudes, and bias
    toward comorbidity and treatment
  • Chronic illness model

  • Essential to treatment of psychiatric illness
  • Combine with knowledge of 12 steps
  • Cognitive behavioral or interpersonal therapy

Other Substance Use Is the Norm
Lifetime Prevalence of Alcohol Dependence in Drug
Alcohol Abuse/Dependence Lifetime Prevalence ()
Estimated Prevalence of Dependence Among 15- to
54-Year-Olds, 1990-1992 (NCS)
NCSNational Comorbidity Survey. Adapted from
Anthony JC et al. Exp Clin Psychopharmacol.
Other Substance Use
  • Use of other drugs complicates treatment of
    alcohol dependence
  • Pharmacotherapies are only available for alcohol
    and opioids (maintenance treatment)
  • Other substance use responds to psychosocial and
    behavioral interventions and treatments
  • Other substance use will be addressed in
    addiction treatment programs

  • Medical and psychiatric comorbidities as well as
    use of other substances complicate the treatment
    of alcohol dependence

Course Summary
  • Pharmacotherapy for alcohol dependence has the
    potential to improve outcomes when integrated
    with the psychosocial and behavioral therapies
    during the first 12 to 18 months of recovery
    the highest risk period for relapse

Case Vignettes
Case 1
  • Susan is a 40-year-old executive who has come in
    for evaluation of a sleep disturbance. Her
    alcohol screen was negative, but she admits that
    she drinks 1 to 2 glasses of wine about 2 times
    per week. She denies any work-related stress,
    legal issues, and drug use. Her family history is
    negative for alcohol dependence, but she does
    state that her marriage is a bit troubled.
  • 1. Is her alcohol use a concern? Why or why not?

  • Case 1 (Contd)
  • Due to the reference made to marital
    difficulties, you obtain a release of information
    and contact her husband. He describes a
    remarkably different situation, stating that he
    is considering a divorce due to Susans drinking.
    He says that she drinks daily, often at least a
    bottle of wine, but she is adept at hiding it so
    he is not sure how much she actually drinks. She
    is performing poorly at her new job in fact she
    is on probation. This is her third job in the
    past 2 years. He has noticed morning sweats and a
    tremor. Her father died a very heavy drinker.

1. What treatment recommendations would you
consider at this time?
  • Case 1 (Contd)
  • Susan returns for a follow up appointment aware
    of your discussion with her husband. She admits
    to drinking one to two bottles of wine per night,
    a marked increase in tolerance, regular
    withdrawal symptoms and dysfunction in multiple
    areas of her life. She is now seeking your help.

1. What is her differential diagnosis? 2. Would
you prescribe a pharmacological treatment? If
so, discuss why and which one.
  • Case 2
  • John is a 24-year-old construction worker who has
    been sent in for evaluation by his employer after
    a urine drug screen revealed cannabis. He admits
    to occasional use, and says it was bad luck
    that resulted in the positive urinalysis. He
    wants to return to work and says he will quit
    using cannabis immediately. He describes regular
    alcohol use, primarily beer, about 4 cans a day
    on weekends. The physical exam is normal,
    laboratory tests are normal, and he does not have
    a family history of alcohol or drug-related

1. What are your concerns about his
presentation? 2. What is your treatment
plan? 3. How would you advise his supervisor?
  • Case 2 (Contd)
  • Six months later you see John in the emergency
    room after he cut off three fingertips at work.
    His drug screen is positive for methamphetamine,
    cannabis, and alcohol. He has been threatened
    with job loss. He lives alone and does not have
    any close friends or family. John admits to daily
    use of a combination of alcohol and other drugs
    his tolerance for alcohol has dramatically
    increased. He states that he is happy with his
    lifestyle, making good money and partying. He
    does want to keep his job.

1. What is your differential diagnosis
now? 2. How would you go about discussing this
situation with John?
  • Case 2 (Contd)
  • John agrees to quit methamphetamine and cannabis,
    but does not want to stop drinking. His
    supervisor wants him clean and sober, or he
    cannot keep his job.

1. How would you advise John? 2. How would you
advise his supervisor? 3. What treatment
recommendations would you make? 4. Would you
prescribe a pharmacological treatment? If so,
discuss why and which one.
  • Slides have been provided by
  • Addiction Technology Transfer Center (ATTC)
  • National Institute on Alcohol Abuse and
    Alcoholism (NIAAA)
  • Bankole Johnson, MD
  • Norman S. Miller, MD
  • John Patz, DO
  • Edwin A. Salsitz, MD, FASAM
  • Marvin D. Seppala, MD
  • Valerie Slaymaker, PhD
  • J. Scott Tonigan, PhD
  • Arnold M. Washton, PhD
  • Clinical Practice Guidelines for Substance Use
    Disorders- Veterans Administration Office of
    Quality and Performance

Acknowledgments (Contd)
  • The faculty would like to acknowledge the ASAM
    staff who made this project come to life
  • Angela Warner
  • Tracy Gartenmann
  • Gionne Graetz

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