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Alcoholism Treatment

in the United States An Overview

Richard K. Fuller, M.D., and Susanne Hiller-Sturmh fel, Ph.D.

On any given day, more than 700,000 people in the United States receive alcoholism treatment in either inpatient or outpatient settings. For many of those patients, detox- ificationwith or without pharmacotherapyis the first step of treatment. The major behavioral approaches currently used in alcoholism treatment include cognitive-behavioral therapy, motivational enhancement therapy, and Alcoholics Anonymous (AA) or related 12- step programs. Clinical studies, such as the Project MATCH trial, have compared the effectiveness of these approaches. Overall, that study detected no significant differences among the three treatments in patient outcome, although certain treatment methodologies may be most appropriate for patients with certain characteristics. Pharmacotherapy with aversive or anticraving medications may supplement behavioral treatment approaches. Brief interventions that are delivered by primary health care providers also have been shown to reduce drinking levels, particularly in nondependent drinkers. K EY WORDS : addiction care; drug therapy; treatment research; United States; behavior therapy; cognitive therapy; Alcoholics Anonymous; motivational interviewing; treatment outcome; inpatient care; outpatient care; detoxification; aftercare; comparative study; patients; predictive factor; anti AOD (alcohol and other drug) craving agents; anti AOD abuse agents; intervention; literature review

Vol. 23, No. 2, 1999 69

A ccording to the 1992 National

Longitudinal Alcohol Epidemio-logic Survey, a national householdsurvey, approximately 7.5 percent of the U.S. population (about 14 million

Americans) abuse and/or are dependenton alcohol (Grant et al. 1994). Further-more, according to the 1993 NationalDrug and Alcoholism Treatment UnitSurvey, more than 700,000 people receivealcoholism treatment on any given day (National Institute on Alcohol Abuse and

Alcoholism [NIAAA] 1997). Of thosepeople, 13.5 percent receive treatment

in either a residential or hospital (i.e.,

inpatient) setting, and 86.5 percent aretreated on an outpatient basis. Theapproaches currently used in the treat-ment of alcohol problems generally havebeen developed based on three sources of information: (1) the experiences of recov-ering alcoholics and the professional staff treating them, (2) research on humanbehavior, and (3) studies of potential med-ications (i.e., pharmacological research).

Most treatment programs encouragepatients to attend regular Alcoholics

Anonymous (AA) meetings or similar

self-help groups that are based on a

12-step philosophy. Many treatmentprograms also use relapse preventiontechniques to help patients acquire the

R ICHARD K. F ULLER , M.D., is director of the Division of Clinical and PreventionResearch at the National Institute on Alco Abuse and Alcoholism, Bethesda, Maryl

S USANNE H ILLER -S TURMHFEL, P H .D.,is a science editor of Alcohol Research& Health.


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intended as maintenance therapy afterthe patients have received initial inpa-tient or intensive outpatient treatment.

Because of escalating health carecosts, the focus in recent years has shiftedaway from inpatient treatment and to-

ward outpatient treatment for all stages of recovery. This shift has resulted in anemphasis on outpatient detoxificationand intensive outpatient services for initialtreatment, approaches that are less expen-sive than inpatient treatment. In addition,the typical length of stay in inpatientprograms has decreased substantially.The effectiveness of inpatient treatmentversus outpatient treatment is controver-sial. Finney and colleagues (1996) con-cluded from their analysis of the findingsof several studies that outpatient treatmentis appropriate for most people withsufficient social resources and withoutco-occurring serious medical and/or psy-chiatric impairment. Conversely, inpa-tient treatment should be retained forclients with serious co-occurring medicaland/or psychiatric conditions as well asfor clients with few social resources and/orenvironments not supportive of recovery.

Detoxification

Sudden cessation of alcohol consumptionin people who have consumed alcoholregularly can lead to a variety of clinicalsymptoms that collectively are calledalcohol withdrawal syndrome. The man-ifestations of alcohol withdrawal canrange from mild irritability, insomnia,and tremors to potentially life-threaten-ing medical complications, such asseizures, hallucinations, and deliriumtremens. Consequently, before beginning long-term alcoholism treatment, many

patients require a detoxification periodduring which they become alcohol freeunder controlled conditions. Depending on the severity of the withdrawal symp-toms, those services can be delivered ineither an inpatient or outpatient setting.

Medically supervised detoxificationfrequently involves treatment with med-ications (i.e., pharmacotherapy), partic-ularly for patients with moderate tosevere withdrawal symptoms. For mostpatients, benzodiazepines a class of sedative medications that affect some of

the same molecules in the brain as doesalcohol are the treatment of choice.

An early randomized clinical trial demon-strated that benzodiazepines effectively prevented the development of deliriumtremens (Kaim et al. 1969). Since thatstudy was conducted, benzodiazepineuse has revolutionized the treatment of alcohol withdrawal syndrome. Initially,benzodiazepines were administered ona predetermined dosing schedule forseveral days, often in gradually tapering doses. Recent studies have shown, how-ever, that lower overall benzodiazepinedoses can be used if the dosage is con-tinually adjusted to the severity of thesymptoms (Saitz 1998). Because ben-zodiazepines have an abuse potential of their own, therapists should not prescribethem after the acute withdrawal period.

Current state-of-the-art alcoholdetoxification begins with an assessmentof the severity of the patients withdrawalsymptoms using such assessment tools asthe revised Clinical Institute Withdrawal

Assessment for Alcohol (CIWA Ar)(Sullivan et al. 1989; Foy et al. 1988).This questionnaire evaluates the pres-ence and severity of various withdrawalsymptoms, such as nausea and vomiting;tremors; sweating; anxiety; agitation;tactile, auditory, and visual disturbances;headaches; and disorientation. Thehigher the patients score is on theCIWA Ar, the greater is his or her risk for experiencing serious withdrawalsymptoms, such as seizures and confusion.

Patients who experience only mild withdrawal symptoms according to theCIWA Ar (i.e., score below 8 points)do not require pharmacotherapy; how-ever, they should be monitored by theirphysician for potential complications.Conversely, patients who experience with-

drawal symptoms that are either moder-ate (i.e., score from 8 to 15 points) orsevere (i.e., score more than 15 points)should be treated with medications, suchas benzodiazepines. Hayashida andcolleagues (1989) demonstrated thatpatients with moderate withdrawalsymptoms can be treated safely on anoutpatient basis.

Hayashida (1998) has indicated thatoutpatient detoxification offers severaladvantages. For example, the patientmay be able to use the same facility for

both detoxification and subsequent long-term outpatient treatment. In addition,the patient may be able to more easily maintain family and social relationshipsand thus experience greater social support.Finally, the costs are lower for outpa-tient than for inpatient detoxification.

Outpatient detoxification is notappropriate, however, for patients whoare at risk for life-threatening withdrawalsymptoms, have other serious medicalconditions, are suicidal or homicidal,live in disruptive family or job situations,or cannot travel daily to the treatmentfacility. Furthermore, outpatient detoxi-fication is associated with significantly lower completion rates compared withinpatient detoxification (Hayashida etal. 1989). Finally, patients undergoing outpatient detoxification are at an increasedrisk of relapse during or shortly afterdetoxification because they have easieraccess to alcoholic beverages. However,long-term outcomes (i.e., more than 6months) do not appear to differ betweenpatients who receive inpatient or outpa-tient detoxification (Hayashida 1998).

Behavioral TreatmentApproaches andTheir Efficacy

The term behavioral treatment isused broadly here to include variousnonpharmacological therapies whoseobjective is to change behavior (i.e., toreduce alcohol consumption). Theseapproaches include behavioral therapy,cognitive therapy, various types of psy-chotherapy, counseling, and other reha-bilitative strategies.

Cognitive-Behavioral Therapy One of the greatest challenges in thetreatment of alcoholism and otheraddictions is the prevention of relapse.Patients have reported numerous factorsthat can trigger relapse. Some of thosefactors are internal to the patient, suchas craving for alcohol, depression, andanxiety. Other factors are external, suchas social pressure to drink; environmen-tal cues associated with drinking (e.g.,visits to bars or restaurants or the smellof alcohol); problems in relationships

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Alcoholism Treatment in the United States


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with other people; and negative lifeevents, such as death or illness of a fam-ily member or loss of job. To preventrelapses resulting from those factors,CBT is designed to help the patientidentify high-risk situations for relapse,learn and rehearse strategies for coping

with those situations, and recognize andcope with craving. Variations of CBTare widely used in alcoholism treatmentunder the label of relapse prevention.In formal CBT, patients practice behav-ioral or cognitive skills to cope withhigh-risk situations through rehearsal,role playing, and homework.

Various studies have evaluated theefficacy of CBT (for more informationon CBT, see the article in this issue by Longabaugh and Morgenstern, pp.78 85). In the Project MATCH study,

which compared the efficacy of threedifferent treatment approaches, CBTachieved outcomes comparable tothose of the other two therapies studied(Project MATCH Research Group1997a ). This result may be surprising,because CBT and other approaches,such as 12-step programs, appear todiffer substantially. A recent review,however, identified common elementsbetween 12-step programs and CBT-based approaches that may help explaintheir comparable results. For example,both approaches encourage the drinkerto pursue activities incompatible withdrinking and to identify and cope withnegative thinking (McCrady 1994).

Motivational Enhancement Therapy

Another psychological-behavioralapproach to alcoholism treatment thatis receiving increasing attention is

motivational enhancement therapy (MET). This method, which is based onthe principles of motivational psychology,does not guide the client step-by-stepthrough recovery but strives to motivatethe client to use his or her own resourcesto change his or her behavior. To thatend, the therapist first assesses the typeand severity of the patients drinking-associated problems. Based on this ini-tial assessment, the therapist providesstructured feedback to stimulate thepatients motivation to change. The

therapist also encourages the client tomake future plans and, during subse-quent counseling sessions, attempts tomaintain or increase the clients moti-vation to initiate or to continue imple-menting change. (For more informa-tion on MET, also see the article in thisissue by DiClemente and colleagues,pp. 86 92.)

AA and 12-Step FacilitationTherapy

AA and similar self-help groups outline12 consecutive activities, or steps, thatalcoholics should achieve during the recov-ery process. For example, these steps spec-ify that drinkers must admit that they arepowerless over alcohol, make a moralinventory of themselves, admit the natureof their wrongs, make a list of everyonethey have harmed, and make amendsto those people. Alcoholics can becomeinvolved with AA before entering profes-sional treatment, as a part of their profes-sional treatment, as aftercare following professional treatment, or instead of professional treatment. In addition, AA members can differ in the degree of their

AA involvement (e.g., how often they attend AA meetings, whether they becomeinvolved with a sponsor, or whether they actively participate in meetings).

Twelve-Step Facilitation (TSF) is a formal treatment approach that has beendeveloped to introduce clients to andinvolve them in AA and similar 12-stepprograms. Thus, TSF guides clientsthrough the first five steps of the AA program and promotes AA affiliationand involvement. For example, therapists

who use TSF actively encourage theirclients to attend AA meetings, maintaina journal of their AA attendance and

participation, obtain a sponsor, and work on completing the first five steps.In addition, the clients receive reading assignments from the AA literature.

Although AA is the most popularself-help group for people with drinking problems, its efficacy has rarely beenassessed in randomized clinical trials.Most research on AA efficacy has com-pared the outcomes of people who didor did not become involved in AA.Those studies have reported a consistentassociation between voluntary AA par-

ticipation and abstinence. Because thestudies are not randomized, however,some factor other than AA involvemenmay account for abstinence. For exam-ple, possibly only people with certaincharacteristics (e.g., a greater motivatioto become abstinent) choose to attend

AA. Such potential differences between AA participants and nonparticipantsmay account for the treatment outcomeConsequently, one does not know whethethe association between AA participatioand abstinence is coincidental, resultsfrom client characteristics or similar factoor is causally related.

To eliminate the possibility that anothefactor is responsible for the observedoutcome and to demonstrate a cause-effect relationship between AA partici-pation and outcome, researchers mustconduct studies in which alcoholic patientare randomly assigned to AA and to onor more other treatments. To date, Walshand colleagues (1991) and the ProjectMATCH Research Group (1997a ) haveconducted two major studies of the efficacy of either AA or involvement in Ausing random patient assignment. Thefindings of the Project MATCH study are summarized in the following sectio

The study by Walsh and colleagues(1991) included 227 alcohol-abusing participants whose employers had referrethem to an employee assistance progra(EAP). The participants were randomlassigned to one of three treatmentoptions: (1) compulsory 3-week inpa-tient treatment followed by 1 year of attendance at AA meetings (i.e., hospital group), (2) compulsory attendanceof AA meetings only (i.e., AA-only group), or (3) participants choice of treatment (i.e., choice group).1 Theparticipants were followed for 2 years

after their entry into the study. During that time, the investigators determinedvarious drinking measures (e.g., absti-nence rates), relapse rates (e.g., measurby the need for hospitalization foradditional treatment), and work-relateoutcomes (e.g., proportion of participant

72 Alcohol Research & Health

1 Although allowing patients to choose their treatmeis not a standard treatment approach, the researcheincluded such a group, because some treatmentresearchers thought that involving patients in planning their treatment would improve outcome.


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who remained employed). The study results can be summarized as follows:

On drinking measures, both the AA-only group and the choice groupfared worse than the hospital group.For example, whereas 37 percent of the hospital group remained absti-nent throughout the entire 2-yearstudy period, only 17 percent of thechoice group and 16 percent of the

AA-only group were continuously abstinent. Similarly, the percentageof patients who did not becomeintoxicated during the study period

was significantly higher in the hos-pital group than in either the choiceor the AA-only group.

The participants in the AA-only group relapsed more often than didparticipants in the other two groups.Thus, 63 percent of the AA-only grouprequired hospitalization for a relapseduring the 2-year study period, com-pared with 23 percent of the hospitalgroup and 38 percent of the choicegroup. As a result of the additionaltreatment required by the AA-only group, the estimated total costs incurredby the hospital group were only anaverage of 10 percent higher than thecosts incurred by the AA-only group.

Work-related outcome variables,such as the proportion of patients

who remained employed over thestudy period, did not differ signifi-cantly among the three groups.

This study is important for severalreasons. First, the counselors involved inthe study allowed their clients to be ran-domly assigned to a treatment. Second,

the study methodology was scientifically sound, because it compared the outcomesof three treatment approaches to whichthe participants had been assigned ran-domly. Third, the results suggest thatan approach which integrates AA withprofessional treatment generally willachieve better outcomes than will referralto AA alone. The study did not address,however, whether inpatient and outpa-tient professional treatments can beequally effective in combination with

AA participation.

Comparison of DifferentTreatment Approaches Project MATCH

Project MATCH was a multisite study primarily focused on identifying patientcharacteristics that would predict whichpatients would benefit most from whichtreatment approach. The study includedtwo groups of participants. One group(i.e., the aftercare sample) was recruitedat four facilities that provided aftercareservices to patients who had receivedinpatient or day-hospital treatment andtherefore had received some kind of intensive treatment. The other group(i.e., the outpatient sample) was recruitedat five outpatient facilities and comprisedpatients who had not received prior inten-sive inpatient or day-hospital treatment.

As a result of their varied treatment his-tories, the two groups differed in certainpatient characteristics. For example, theaftercare patients were more severely alcohol dependent when entering thestudy than were the outpatients.

Within both the aftercare and out-patient samples, participants were ran-domly assigned to receive either CBT,MET, or TSF. All interventions weredelivered over a 12-week period inindividual outpatient counseling sessionsand were based on treatment manuals.To determine treatment efficacy, the

study assessed several drinking-relatedvariables. The primary variables, which

were analyzed for the 90 days preced-ing treatment, the year following treat-ment, and the 90 days preceding the3-year followup, were the percentageof days on which the participants wereabstinent and the number of drinksconsumed per drinking day.

Outcome Differences Between Aftercare and Outpatient Samples The study found that the aftercare sam-ple generally achieved better treatmentresults than did the outpatient sample.For example, at 1-year followup, 35percent of the aftercare patients hadremained continuously abstinent, com-pared with 20 percent of the outpatientsample. Similarly, a higher percentageof the aftercare sample than of the out-patient sample was abstinent between9 and 12 months after treatment or

was drinking moderately without prob-lems during that period (see table).Because the patients were not randomly assigned to either the aftercare or outpa-tient sample, however, one cannotconclude that aftercare is superior tooutpatient treatment. Instead, a variety of factors may help explain why theaftercare patients more commonly achieved continuous abstinence. For

Vol. 23, No. 2, 1999 73

Overall Outcomes of Clients in the Aftercare and Outpatient* Groups of the ProjectMATCH Study

Percentage of Clients Basedon Treatment Group**

Outcome Variable Aftercare Outpatient

Continuously abstinent for 1 year

following treatment35 20

Abstinent between 9 and 12 monthsafter treatment

46 30

Drinking moderately without any problemsbetween 9 and 12 months after treatment

7 12

*Aftercare clients were recruited into the study after receiving either inpatient or intensive outpatient treatment.Participants in the outpatient group received no intensive treatment before entering the study (Project MATCH1997 a ).**The numbers represent the proportion of clients in the aftercare and outpatient samples who fulfilled theoutcome variable indicated. For example, 35 percent of all aftercare clients and 20 percent of all outpatientclients remained continuously abstient for 1 year following treatment.



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example, the total amount of care receivedmay contribute to treatment outcome,because the aftercare patients had receivedprevious care in addition to the treat-ment approaches included in the study.

Alternatively, the period of enforcedabstinence that the aftercare patientsexperienced during their inpatient treat-ment may have had a beneficial effect.

Outcome Differences Among Treatments

Although Project MATCH was notprimarily concerned with comparing the three treatments for differential effi-cacy, the study s design allowed suchanalyses because the participants wererandomly assigned to the therapies.

In the aftercare sample, no differences were found in the efficacy of CBT, MET,and TSF during the year following treatment. Similarly, no differences oronly small ones existed among the out-patients in the efficacy of the three treat-ments. Those differences that did existusually indicated that TSF was mostefficacious. For example, significantly more TSF-treated outpatients (i.e., 24percent) than either MET- or CBT-treated outpatients (i.e., 14 and 15 per-cent, respectively) were continuously abstinent for 1 year after treatment(Project MATCH Research Group1997a ). Similarly, the abstinence rateduring the preceding 90 days both atthe 1- and 3-year followups was slightly higher among the TSF-treated outpa-tients than among the MET- and CBT-treated outpatients (Project MATCHResearch Group 1998a ).

Some differences existed in the timecourse in which the three treatmentsimproved the outpatients drinking pat-

terns; no such differences existed, how-ever, among aftercare patients. Thus,during the 3 months of therapy, only 28 percent of MET-treated outpatients,compared with 41 percent of the CBT-and TSF-treated outpatients, were con-tinuously abstinent or drank moderately

without problems (Project MATCHResearch Group 1998b). During the 3years following treatment, however, thepercentage of abstinent days and numberof drinks per drinking day reported by the MET-treated outpatients were com-

parable with those of the CBT- andTSF-treated outpatients. These findingssuggest that patients may achieve controlover their drinking problems more slowly

with the less directive MET approach

than with the CBT or TSF approaches,but nevertheless experience long-termoutcomes comparable with those of thetwo other therapies.

Patient Characteristics Predicting Treatment Outcome The primary goal of the Project MATCHstudy was to determine patient charac-teristics that could predict which treat-ment approach would be most effectivefor a given patient. The study identifiedfour patient-treatment matches onein the aftercare sample and three in theoutpatient sample.

First, when the aftercare patients wereclassified according to the severity of their dependence, those patients whohad been more severely dependentachieved better results (i.e., had moreabstinent days and fewer drinks perdrinking day) with TSF than with CBT

(Project MATCH Research Group1997b). For example, among the TSF-treated patients, the most severely dependent were abstinent on 94 percentof the days after treatment compared

with abstinence on 84 percent of thedays in the most severely dependentCBT-treated patients. Conversely, theleast severely dependent CBT-treatedpatients averaged 94 percent of abstinentdays after treatment, compared with 89percent of abstinent days in the leastseverely dependent TSF-treated patients.

These findings suggest that among patients who have already received inptient treatment, TSF may be moreappropriate for highly dependent patients

whereas CBT may be more appropriafor less severely dependent patients.

Second, in the outpatient sample,MET was the most effective approachin the treatment of patients with highlevels of anger (as determined by theSpielberger Anger Scale). MET-treatedoutpatients with greater levels of angehad a greater percentage of abstinentdays and fewer drinks per drinking dathan did outpatients with similar angerlevels who were treated with CBT. Forexample, MET patients with high angelevels were abstinent on 85 percent of thdays compared with 75 percent of abstinent days for CBT patients with highanger levels (Project MATCH ResearcGroup 1998b). This match betweenanger level and treatment approach waobserved at the 1-year followup andpersisted at the 3-year followup (ProjecMATCH Research Group 1998a ).

Third, the Project MATCH resultsindicated that TSF and the resulting

AA involvement was particularly effectifor outpatients whose social networks(e.g., family members and friends) supported drinking. At the 3-year followupthose patients had better outcomes withTSF than with MET (Longabaugh et al1998). Thus, outpatients in the uppermedian2 for a supportive drinking net-

work who received TSF had 83 percenof abstinent days, compared with 66percent of abstinent days among similapatients receiving MET. AA involvemen

was an important mediator of this effecTSF-treated patients whose social networsupported drinking and who becameinvolved in AA had 91 percent of abst

nent days compared with 60 percent ofabstinent days for similar patients whodid not become involved in AA. AA involvement also enhanced treatmentoutcome in patients whose social net-

works were supportive of drinking and who received either MET or CBT;however, this beneficial effect of AA involvement was smaller than among patients receiving TSF.

Researchers also observed the rela-tionship among a drinkers social network

AA involvement, and treatment out-


A new social network of friends

who support abstinence appears to be a key element

in recovery.


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come in a recent long-term study of patients at 15 Department of Veterans

Affairs hospitals3 (Humphreys et al. inpress). The study found that replacing patients social networks of drinking friends with the AA fellowship was atleast in part responsible for the betteroutcomes observed in clients who becameinvolved with AA. Thus, treatmentapproaches that facilitate the clientsinvolvement in 12-step programs may be beneficial, particularly for clients

whose social networks support drinking.For those people, a new social network of friends who support abstinence appearsto be a key element in recovery.

Fourth, the Project MATCH findingsindicated that for the first 9 monthsfollowing treatment, outpatients who

were low in psychiatric severity as assessedby the Addiction Severity Index psychi-atric subscale experienced more abstinentdays and fewer drinks per drinking day

when treated with TSF than with CBT. At the 1-year followup, however, thisdifference between the treatment groupsno longer existed.

Overall, the results of Project MATCHprovide only limited support for thehypothesis that patients can be matched

with optimal treatments based on patientcharacteristics, because only 4 out of a possible 21 matches (based on thenumber of treatments and patient char-acteristics evaluated) were detected.Furthermore, one of those four matcheshad dissipated within 1 year after treat-ment. The findings suggest, however,that some incremental improvement inoutcome occurs if aftercare patients arescreened for severity of dependence andoutpatients are screened for anger andtype of social network prior to treatment.

Pharmacotherapy

Currently, therapists primarily use twotypes of medications in alcoholismtreatment: (1) aversive medications,

which deter the patient from drinking,and (2) anticraving medications, whichreduce the patients desire to drink.

Aversive Medications

The most commonly used aversivemedication in alcoholism treatment isdisulfiram, which has been availablesince the late 1940s. The medicationcauses an unpleasant reaction (i.e., nau-sea, vomiting, flushing, and increasedblood pressure and heart rate) whenthe patient ingests alcohol. Early clinicalstudies of disulfiram therapy reportedfavorable outcomes (i.e., improvedabstinence rates) among recovering alcoholics; however, most of those stud-ies were not conducted according to thecurrent standards of controlled clinicaltrials (Fuller and Roth 1979).

Conversely, according to one large, well-designed study, disulfiram did notincrease the rate of sustained abstinenceor time to relapse among the patients(Fuller et al. 1986). In addition, only a subgroup of study participants (i.e.,patients who showed evidence of greatersocial stability) drank less frequently

when taking disulfiram than did patients with similar characteristics who receivedan inactive medication (i.e., a placebo)or no medication. Furthermore, absti-nence was related to the patients com-pliance with the medication regimen(i.e., whether the patients continued totake the medication regularly). Becausepoor compliance can nullify disulfiramseffectiveness, some programs requirestaff members or relatives to observethe patient ingesting the medication.

A randomized study (Chick at al. 1992)found that supervised disulfiram admin-istration was more beneficial than super-

vised vitamin administration.

Anticraving Medications Various brain chemicals have been impli-cated in mediating alcohols pleasanteffects and in contributing to the devel-opment of tolerance to and craving foralcohol. Accordingly, researchers haveattempted to prevent alcohols pleasanteffects and craving for alcohol by devel-oping medications that interfere withthe actions of those brain chemicals.

Two of those medications are naltrex-one and acamprosate.

Naltrexone was the first agent innearly 50 years to be approved by theFDA for alcoholism treatment. Theapproval was based on two randomizedclinical trials reporting that naltrexonecombined with psychosocial treatmentreduced 3-month relapse rates from 50percent among patients who received a placebo to 25 percent among patients

who received naltrexone (OMalley et al.1992; Volpicelli et al. 1992). As withdisulfiram, a recent study found thatcompliance with naltrexone was criticalfor obtaining favorable outcomes(Volpicelli et al. 1997). Naltrexone actsby interfering with the actions of key brain chemicals called endogenous opi-oids. In response to alcohol, endoge-nous opioids activate certain brain cellsand induce some of alcohols pleasanteffects (e.g., euphoria and reduced anxi-ety). By blocking the actions of endoge-nous opioids, naltrexone prevents alcoholfrom exerting its pleasant effects andmay reduce the patients desire to drink.

Acamprosate is another medicationaimed at reducing alcohol craving.Researchers in Europe have studied thedrug extensively; however, it is not yetcommercially available in the UnitedStates. Scientists still do not know acam-prosates precise mechanism of action.However, the drug appears to interact

with a certain type of receptor (i.e., theN -methyl-D-aspartate [NMDA] receptor)that is located on the surface of somebrain cells and mediates the effects of another important brain chemical, glu-tamate. Controlled European studieshave found that acamprosate treatmentcan almost double the abstinence rateamong recovering alcoholics (Sass et al.

1996). Researchers in the United Statesare currently conducting a multisite ran-domized clinical trial of acamprosate.

Further Directions in Pharmacotherapy In addition to the medications describedhere, scientists are evaluating other phar-macotherapeutic approaches to alco-holism treatment (for more informationon recent advances and future trends inpharmacotherapy, see the article in this

Vol. 23, No. 2, 1999 75

2The upper median is the 50 percent of people in a sample who have the highest scores on a given variable(e.g., on an index of a network supportive of drinking).3The patients in that study had not been assignedrandomly to a specific treatment approach.



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issue by Johnson and Ait-Daoud, pp.99106). For example, some researchersare testing medications targeting otherbrain chemicals (e.g., serotonin) that havebeen implicated in mediating alcoholseffects. To date, however, clinical trialsof serotonin-targeting agents have notdemonstrated efficacy in alcohol-depen-dent patients (Kranzler et al. 1995;

Johnson et al. 1996).Some alcoholics suffer from co-

occurring psychiatric conditions, suchas depression and anxiety. In somepatients, these psychiatric conditionsprecede, and possibly even precipitate,alcohol abuse and dependence. In otherpatients, the psychiatric condition resultsfrom long-term alcohol abuse. It is plau-sible that at least in the former groupof patients, treatment of the psychiatricillness may decrease alcohol consump-tion, because the patients no longer needto resort to alcohol to alleviate anxiety or depression. Three clinical trials of antidepressant medication therapy foralcoholism found that this treatmentimproved the patients depression(Mason et al. 1996; McGrath et al.1996; Cornelius et al. 1997). However,only one of those studies found thatantidepressant therapy caused a majorchange in drinking levels (Cornelius et al.1997). Studies of the anti-anxiety med-ication buspirone in alcoholic patientshave yielded conflicting results (Kranzleret al. 1994; Malcolm et al. 1992).

Finally, other clinical trials are evalu-ating whether treatment efficacy can beincreased by combining medications,because combination therapy is effectivefor the treatment of many other condi-tions, such as high blood pressure.Researchers and clinicians hope that theseapproaches will yield effective therapies

to help alcoholics achieve long-termabstinence.

Brief Interventions

Many people with alcohol-related prob-lems do not seek the help of an alco-holism treatment specialist but receivetheir care from a primary care provider.Usually conducted in a primary caresetting, brief intervention treatmentslast for up to four or five office visits.

In general, such interventions begin with an assessment of the extent of thepatients alcohol-related problems (e.g.,impaired liver function or alcohol-relatedproblems at work) and a discussion of the potential health consequences of continued drinking. The health careprofessional then offers advice on strate-

gies to either cut down on drinking (fornon-alcohol-dependent patients only) orabstain from drinking (for both depen-dent and nondependent patients). Suchstrategies can include setting specificgoals for reducing the number of drinksconsumed per day or per week andagreeing to written contracts that specify measures of progress toward changes indrinking behavior (for more informationon such contracts, see the article in thisissue by Higgins and Petry, pp. 122127).

Two controlled studies conductedin the United States and Canada haveinvestigated the efficacy of brief interven-tions. Those studies demonstrated thatbrief interventions reduced drinking (Fleming et al. 1997; Israel et al. 1996),alcohol-related problems (Israel et al.1996), and the patients use of health

care services (Fleming et al. 1997). Thecurrent challenge is to educate healthcare professionals about and motivatethem to use brief interventions (for moreinformation on brief interventions, seethe article in this issue by Fleming andManwell, pp. 128 137).

Conclusions

The past decade has seen remarkableadvances in alcoholism treatment

research. Researchers and treatmentproviders now have a better understanding of the effectiveness of nonpharmaclogical treatments and of key elementsin 12-step programs. In addition, researchon effective pharmacotherapies for alcholism is entering a new era. Finally,brief interventions delivered in primarcare settings have been shown to beeffective in reducing drinking among people who have alcohol-related problemor who are at risk for such problems.

Substantial challenges remain, however, before the results of this researchcan be translated into improved treatmenoutcomes. For example, many treatmenprograms do not use pharmacotherapiesprimarily for philosophical reasons

that is, treatment providers are reluctanto substitute one drug (i.e., the treatmenmedication) for another (i.e., alcohol).Similarly, many primary care providermay not be aware of the usefulness ancorrect use of brief interventions. Consequently, all health care professionals

working with people who abuse orare dependent on alcohol particularlyaddiction professionals must stay informed about improvements in alco-holism treatment and novel treatmentoptions. Otherwise, patients with

alcohol-related problems who mightbenefit from new approaches, such aspharmacotherapies, might be deprivedof an opportunity for achieving long-term recovery.s

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AND TORLEY , D. Disulfiram treatment of alcoholismBritish Journal of Psychiatry 161:84 89, 1992.

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