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Evidence-Based Treatments for Alcohol Use Disorder

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By: Sylvina Raver, Ph.D.

Alcohol use disorder, or AUD, is a medical diagnosis given to people who seriously struggle to control their drinking. Approximately 7.2% of American adults suffer from AUD, the consequences of which are hard to overstate. The Centers for Disease Control and Prevention (CDC) estimate that excessive alcohol use contributes to approximately 88,000 deaths per year, and costs the US economy billions of dollars annually in health care costs, criminal justice, automobile accidents, and lost workplace productivity. For those who seek treatment for excessive drinking – either voluntarily or through court-mandated recovery programs – the traditional treatment method has been a faith-based 12-step program, such as Alcoholics Anonymous (AA). For many people, AA is a life-saving experience. But for many others, AUD persists despite determinedly “working the 12 steps” of the program.

A recent article published by The Atlantic calls into question Americans’ reliance on 12-step programs as the primary method to treat AUD. The article’s author claims that compelling data in support of AA’s efficacy are seriously lacking, and that accumulating scientific evidence argues against many tenants of the program. In contrast to AA, which is notoriously difficult to study, many other treatments have been rigorously tested, and now have large bodies of research that support their efficacy. Since its passage in 2010, the Affordable Care Act (ACA) has mandated that health insurance plans and state-run Medicaid programs must cover substance abuse services, which include treatments for AUD, as an “essential health benefit.” However, the law does not specify which treatment programs are the most effective and thus should be covered. As private insurers and government health care programs expand coverage for AUD treatments under the ACA, it’s crucial to consider those methods that have sound experimental support and that are in accordance with what modern neuroscience tells us about disorders of alcohol use and abuse.

The precise mechanisms that underlie AUD, as well as the genetic underpinnings responsible for people’s differential susceptibility to the disease, are the focus of ongoing research, and accumulating evidence indicates an intersection between the brain’s arousal, reward, and stress systems. Early use of alcohol is pleasurable and positively reinforcing, but the drug can take on negative reinforcing qualities during the transition to dependence, as users drink to prevent negative consequences, including withdrawal symptoms. Chronic alcohol abuse leads to adaptations in brain networks and neurotransmitters that control motivation, reward, stress, and arousal. If AUD’s progression is not halted through interventions and appropriate treatments, these alcohol-induced neuroadaptations can worsen over time and contribute to the deadly nature of severe AUD.

Fortunately, treatments for AUD can be extremely effective, although many of them are not well known outside of the medical and addiction communities. The 12 steps outlined by Alcoholics Anonymous have become synonymous with treatment for alcohol abuse in the US, and are deeply entrenched in rehabilitation culture. When it was introduced in the 1930’s, AA was modern in treating alcoholism as a disease, rather than simply as a failure of moral character. However, some of its central tenants are now at odds with our current knowledge of AUD. For example, AA members are instructed to admit that they are “powerless” over alcohol and to completely abstain from drinking. While this approach may be necessary for some individuals, total alcohol abstinence can actually be detrimental to many patients’ recovery process. Basic and clinical neuroscience research has shown that complete abstinence from alcohol can actually increase one’s urge to drink, leading animals and humans to binge once they have access to alcohol again. Furthermore, the type of black-or-white dichotomy inherent to AA – either completely abstinent or not, alcoholic or not – does a disservice to the vast majority of those with AUD who land along a spectrum of problematic alcohol use. The newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) combines two previously distinct disorders, alcohol abuse and alcohol dependence, into the single, overarching Alcohol Use Disorder (AUD). AUD is further classified as mild, moderate or severe, depending on the number of criteria that a person meets, and treatment programs must be individually adopted for the severity of one’s disorder. Approximately 15% of adults with AUD fall on the severe end of the spectrum and require intensive treatment for their disease. However, the remaining 85% fall in to the mild or moderate categories, and seem to benefit most from brief interventions by medical professionals that help them change unhealthy drinking habits.

Twelve-step programs, such as AA, are not the only options available for AUD treatment, and many approaches are supported by decades of solid research. These treatment practices are collectively called “evidence-based treatments” and can be broadly classified as pharmacotherapies and behavioral therapies. Many experts in addiction medicine believe that pharmacotherapy, or medication-assisted treatment, represents a powerful yet underutilized tool to address moderate and severe AUD. A recent panel convened by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a report that describes the use of FDA-approved medications in clinical practice for the treatment of AUD. These include:

  • Naltrexone (in both oral and extended-release injectable forms), which blocks opioid receptors in the brain to interfere with the rewarding effects of drinking and reduces cravings for alcohol,
  • Disulfiram, which interferes with alcohol degradation to produce an unpleasant reaction if a person drinks alcohol,
  • Acamprosate, which acts on the GABA and glutamate neurotransmitter systems to help reduce the effects of alcohol withdrawal, including anxiety, insomnia, restlessness, and dysphoria.

The NIAAA/SAMHSA panel concludes, “Medication-assisted treatment shows a lot of promise in reducing alcohol use and promoting abstinence in patients diagnosed with alcohol use disorder.”

            Behavioral therapies are also highly effective for addressing AUD, and can be combined with pharmacotherapies or pursued on their own. These approaches help people to modify their attitudes and behaviors about alcohol, become engaged in their treatment, and increase their arsenal of coping skills to better handle stressors and environmental cues that may trigger problem drinking. Evidence-based behavioral therapies for AUD include:

  • Cognitive Behavioral Therapy, which recognizes that learning processes play a central role in alcohol addiction and helps patients to enhance their self-control through developing effective coping strategies,
  • Contingency Management Interventions/Motivational Incentives, which involve giving patients tangible rewards (often financial) to reinforce positive behaviors, such as reducing their alcohol use, attending counseling sessions, and completing goal-related activities,
  • Motivational Enhancement Therapy, which helps patients resolve any ambivalence about engaging in AUD treatment to stop or reduce their alcohol use, and aims to evoke rapid and internally motivated changes, rather than guide the individual stepwise through the recovery process,
  • Community Reinforcement Approach Plus Vouchers, a 24-week outpatient therapy that uses a range of recreational, familial, social, and vocational reinforcers, combined with material incentives, to make a non-alcohol or responsible-alcohol-using lifestyle more rewarding than the alternative,
  • 12-Step Facilitation Therapy (such as Alcoholics Anonymous), which is an active engagement strategy to promote abstinence with the support of 12-step self-help groups and adherence to the principals of: 1) acceptance of the chronic, progressive nature of the disease; 2) surrender to a higher power/fellowship of the support structure; and 3) active involvement in 12-step meetings and related activities.

Of the estimated 17 million Americans who suffer from AUD, only about 13% receive any type of treatment. The ACA may have the power to drastically improve this situation with its emphasis on primary prevention, so that patients struggling with mild symptoms of AUD can be more easily identified before the disorder progresses. Addiction experts and other health care providers have identified the crucial roles that general and mental healthcare settings – including primary, urgent, and emergency care – can play in early identification of problematic alcohol use, and in providing initial brief interventions for patients. These types of early screening and intervention efforts, combined with evidence-based treatments, can provide hope to the tens of millions of Americans struggling with AUD.

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Written by sciencepolicyforall

May 20, 2015 at 9:00 am

Posted in Essays

Tagged with , , , ,

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