New research is fundamentally changing our understanding of both addiction and recovery. Dozens of new alcoholism medications are in preclinical or clinical testing; many of them target novel pathways, such as the exaggerated stress response that both humans and animals develop under the influence of alcohol addiction, an amped up version of the typical release of adrenaline and other chemicals when we perceive a threat.
But neither new treatments nor existing drugs are making their way to enough patients, says Mark Willenbring, director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. An antirelapse drug called naltrexone, for example, was approved in the 1990s but is prescribed for only about four percent of those with alcohol dependence. It blocks the brain’s reward mechanisms, which are often triggered by drinking.
Willenbring is promoting a new system, in which patients are treated by their primary-care doctors in office visits. He says this model will appeal to people who either don’t want or don’t need lengthy counseling or inpatient programs. Willenbring spoke with Technology Review about what works in treating alcohol addiction.
TR: What’s the biggest problem with the treatments for alcohol dependence available today?
MW: The number-one problem is that so few people with alcohol dependence actually get treatment. Over the lifetime, it’s probably fewer than 10 percent.
TR: Why so few?
MW: Most people say they don’t need treatment, or that they can handle it on their own.
Part of the reason for that is the interaction between the treatment system and the perceived need for treatment. For example, if the only treatment for depression is to be hospitalized when seriously depressed and to undergo electroconvulsive therapy, that’s a high threshold. Most of us would have to be really badly off to go get that. But if treatment meant getting a prescription from your family doctor, that’s a much lower threshold. Before that [became available], very few people with depression got treatment, because the treatment was so draconian.
The treatment system we currently have [for alcohol dependence] is separated from mainstream health care and mainstream mental-health care. It was devised in 1975, when all we had for treatment was basically group counseling and AA. So when people think about getting treatment for drinking, they envision going somewhere like the Betty Ford Center.
That system has three main problems: First, most people don’t want it; they have to be forced into it. The second problem is that patients within the general health and mental-health system are not getting located or treated. Third, because the programs are built around counseling, they are not staffed by medical personnel. So there’s no one there to talk about medications available for treating alcohol dependence. And a lot of counselors don’t really believe in [medication].
Consequently, the new treatments we’re developing are not being implemented. Try finding a doctor who knows how to prescribe naltrexone for alcohol dependence. They’re very hard to find.
TR: Is there evidence that this medical approach is really effective?
MW: A large study testing two different medications and psychotherapy was published in the Journal of the American Medical Association last May. Some patients got a drug [naltrexone or another medication, acamprosate] and medical management–an initial hour-long discussion session with a nurse, then nine more short sessions to talk about their progress. Other patients got a drug and counseling. The study found that naltrexone in combination with medical management had the best outcome, better than specialized counseling. Other research suggests the same thing. Not everyone needs to go to some specialized psychotherapy. Naltrexone with medical support can be equally effective.
People don’t want to go talk to a psychotherapist; they don’t want to go bare their soul in front of a group. They want to see a doctor or a nurse for disease management. A recent trial for depression found that cognitive psychotherapy is as effective as medication for mild to moderate depression and has many advantages, like no side effects. So all the study sites geared up to provide behavioral therapy, but few people wanted it. They almost all wanted medication. That says a great deal about what people want as opposed to what professionals want to give them. I think the same thing is going to be true for alcoholism.
TR: Many people consider counseling an integral part of the treatment for addiction, either to help people understand what triggers their addiction or to help them develop coping mechanisms. Do you think medically focused treatment for alcoholism will backfire by excluding this?
MW: Right now, people who seek treatment are more likely to have severe problems, and they probably need intensive treatment. But the garden-variety alcoholism is not being treated at all. Many people with alcohol dependence are working and have families, and they may be functioning quite well. I think these are the people who can respond to a medical approach. The medications we have are no magic bullet, but they significantly decrease risk of relapse.
TR: So how will treatment change in the next decade?
MW: Over the next 10 years, I think we’ll see a paradigm shift in the kinds of treatments that are available and how they are offered. We’ll have much more accessible and acceptable options. As what are perceived as the adverse effects of treatments, such as withdrawal symptoms, decrease, you’ll see many more people seeking help.
TR: What are some of the new drugs in development?
MW: One drug being tested in clinical trials is topiramate, an anticonvulsant [used to treat epilepsy]. It acts on the GABA/glutamate system, [two neurotransmitters] that are involved in the reward and protracted withdrawal of alcohol dependence.
Other drugs in development target the stress-response system. Drugs that target corticotropin-releasing factor (CRF), a molecule involved in the stress response, are thought to help by dampening this exaggerated response.
Endocannabinoids [which target the same receptors as marijuana] are another interesting set of drugs, which are probably involved in the reward pathway. Antagonists such as rimonobant have shown promise in animal models. [Rimonobant was recently approved as a weight loss drug in Europe.]
TR: How will the NIAAA help get new medical treatments to patients?
MW: We developed a clinician’s guide. With the old model, doctors would screen patients for alcohol dependence and then refer them to a treatment center. That can be quite successful if people are willing to go. However, few are going, so we’re encouraging GPs [general practitioners] and psychiatrists to begin treating patients in their practice.