Scope of the Problem
AUDs are prevalent in the United States and often go untreated. NIAAA’,s National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large general-population survey conducted in 2001–,2002, estimated the prevalence of alcohol abuse and dependence at 4.65 percent and 3.81 percent, respectively ( Grant et al. 2004 ). Alcoholism treatment options.
Using NESARC results, Cohen and colleagues (2007) reported that only 14.6 percent of those with a lifetime history of alcohol abuse or dependence have received treatment. In another study that used NESARC results, Dawson and colleagues (2005) reported on people who experienced the onset of alcohol dependence at some point before the year prior to the survey. In this group, 25 percent still were alcohol dependent, 27.3 percent were in partial remission, 11.8 percent were in full remission but drinking at levels or patterns that put them at high risk for relapse, 17.7 percent were low-risk drinkers, and 18.2 percent were abstainers during the year prior to the survey.
Only 25.5 percent of these respondents reported ever receiving treatment. Among them, 3.1 percent participated in 12-step programs, 5.4 percent received formal treatment only, and the remaining 17 percent participated in both 12-step and formal treatment programs ( Dawson et al. 2006 ).
Findings from this survey show that there is a wide range of recovery from alcohol dependence in the general population, from partial remission to full abstinence. The track of this disease is not clear cut—,some people appear to recover from alcoholism without formal treatment. Others may cycle into and out of dependence throughout their lifetime despite repeated attempts to achieve sobriety ( NIAAA 2006 ).
Best treatment options for alcoholism
Comparing Treatment Options: Project MATCH and the COMBINE Study
Because no single treatment approach is effective for everyone with alcohol dependence, clinicians and researchers proposed that assigning patients to treatment based on specific needs and characteristics would improve outcomes. NIAAA initiated Project MATCH in 1989 to test this theory. Patients—,who were characterized according to factors such as severity of alcohol involvement, cognitive impairment, psychiatric severity, gender, motivational readiness to change, and social support for drinking versus abstinence—,were randomly assigned to 12-step facilitation, cognitive–,behavioral therapy, or motivational enhancement therapy. Patients were followed at 3-month intervals for 1 year after completion of the 12-week treatment period and were evaluated for changes in drinking patterns, functional status/quality of life, and treatment services utilization. The study found that patients with low psychiatric severity were best suited to 12-step facilitation therapy. These patients had more abstinent days than those treated with cognitive–,behavioral therapy. Overall, Project MATCH participants showed significant improvement in percentage of abstinent days and decreased number of drinks per drinking days, with few significant outcome differences among the three treatment groups ( Project MATCH Research Group 1997 ).
Following Project MATCH, the next step for evaluating treatment options was a large-scale study of medications for alcohol dependence. Combining Medications and Behavioral Interventions for Alcoholism, or the COMBINE Study, evaluated the efficacy of naltrexone and acamprosate, both alone and in combination, with medical management (i.e., patients had brief sessions with a health care professional) with and without behavioral therapy. The behavioral treatment integrated aspects of cognitive–,behavioral therapy, motivational interviewing, and 12-step facilitation. Patients who received naltrexone, behavioral therapy, or both demonstrated the best drinking outcomes after 16 weeks of treatment. Acamprosate showed no evidence of efficacy, with or without behavioral therapy ( Anton et al. 2006 ).
In addition to naltrexone (and an injectable, long-acting form of naltrexone) and acamprosate, disulfiram (Antabuse
) also is approved to treat alcohol dependence. Naltrexone helps to reduce the craving for alcohol after someone has stopped drinking. Acamprosate is thought to work by reducing symptoms that follow lengthy abstinence, such as anxiety and insomnia. Disulfiram discourages drinking by making the patient feel sick after drinking alcohol. Other types of drugs are available to help manage symptoms of withdrawal.
As shown in COMBINE, no single medication or treatment strategy is effective in every case or in every person. As research exploring the neuroscience of alcoholism continues to pave the way for new medications, studies also have sought to better understand why some behavioral interventions are more effective than others. The articles to follow in this special issue examine a broad range of topics relevant to developing and applying new treatment tools and methods.