Successfully treating problem drinking

Thanks to the availability of effective medications, managing patients with alcohol dependence has become a realistic goal for primary-care clinicians.

An estimated 5% of patients encountered in primary care are alcohol-dependent.1 Traditionally, clinicians have referred these patients to specialists, but with the advent of effective medications to aid recovery, office-based primary care has become a viable option for treatment.

All too often, misuse of alcohol goes undetected.2 Those who fit the stereotype of severe alcoholism—unemployed, alienated from family, and sometimes even homeless—are easy to identify. But most alcoholics have jobs and intact families and can't be identified by their outward circumstances in life or their medical records.

Clinicians should suspect alcohol dependence when the patient complains that things are not going well at home, at work, or in other areas of daily life. In these cases, it is appropriate to pose questions with regard to alcohol and drug use. Such questions are also indicated when patients present with any of the typical medical consequences of alcohol abuse: liver problems, GI symptoms, insomnia, labile or treatment-resistant hypertension, depressive symptoms, anxiety reactions, erectile dysfunction, and sexually transmitted infections.

In fact, problems with alcohol and risky drinking are sufficiently common that clinicians should screen patients routinely without waiting for warning signs.3 A simple screen recommended by the National Institute on Alcoholism and Alcohol Abuse consists of a single question: “How many times in the past year have you had five or more drinks in a day?” (For women, the cutoff amount is four drinks in a day.4) Most of the time, the answer to this question will identify situations that merit further investigation.5

If the screen is positive, get a sense of the degree to which alcohol is causing problems in the patient's life. Family and other relationships are likely to be affected, and there will probably be absenteeism or other problems at work. Anxiety or depressive symptoms are typical, although these may not reach the level of a full-fledged psychiatric diagnosis.

nquire further for symptoms of dependence. If you ask directly, most patients will say they are in control of their drinking. More useful information may come in responses to questions asking whether they've set rules for themselves about alcohol —which many people do when they realize they're finding it hard to regulate their consumption. Patients who admit to difficulty adhering to such rules are at least motivated to take some action, and this motivation can be an opening to recovery.

Withdrawal symptoms are another indication of dependence: Ask patients whether they feel shaky after a night of drinking or have experienced shakiness when trying to quit in the past. Some patients with problem drinking have interconnected conditions, such as drug addiction, depression, or anxiety disorders. Identifying and treating comorbid conditions is advised.

The clinical response

Once excessive drinking is identified, evaluate for liver and cardiovascular damage (alcoholics more often die of cardiovascular than hepatic complications). A complete physical exam is also recommended.

Assess the desire to change a drinking habit in a nonjudgmental manner. With open-ended questions, draw out from the patient what he or she likes about drinking. Then ask if there are any downsides.

Some patients with problem drinking respond to brief interventions—just a few minutes of feedback and education on risks or consequences, a recommendation about low-risk drinking, a negotiated agreement on daily and weekly limits, and a follow-up session to track progress. Those who are dependent may be more receptive to changing their drinking than accepting a diagnostic label.

If patients try but are unable to control their drinking, it is important to allay their guilt and shame. Emphasize that their loss of control is not their fault, but due to an abnormality in part of the brain, the pleasure-reward system. This abnormality results from being dealt an unlucky set of genes. If patients ask, say yes, this is alcoholism. If not, use your judgment when to convey this diagnosis and do so with warmth, concern, and compassion.

Stress that there are effective treatments if they want to make changes in their lives. For interested patients, lay out the options and offer a choice: referral to a specialist or a series of visits with you. Most will initially choose the latter, giving themselves an opportunity to learn if they can get a handle on their problem with minimal, low-cost, unobtrusive help and avoiding the stigma and shame that they might feel when walking into an alcoholism treatment setting or an Alcoholics Anonymous meeting.

Research suggests that many patients with less severe alcohol dependence may do as well in primary care as in specialized treatment settings. Those who need intensive treatment will accept it more willingly if initial assistance from the clinician provides real hope that alcoholism can be overcome.

Medication options

Three oral drugs and one injectable agent are approved for treating alcohol dependence. New research indicates that topiramate, a medication used for epilepsy and migraine, might also be useful for alcohol dependence, but it is not yet approved for this indication. A brief description of each agent follows:

Oral naltrexone (Depade, ReVia) blocks opioid receptors in the brain. Alcohol produces pleasurable effects through the release of endogenous opioids (endorphins), and naltrexone blocks that reward. The drug has been shown to reduce craving when alcohol is withdrawn.

This is usually the first drug clinicians prescribe. Convenience is a factor—it need be taken only once daily. The efficacy of oral naltrexone in primary care was recently validated in a large randomized controlled trial.6 Naltrexone is safe and usually well tolerated. About 10% of patients experience significant nausea, which usually remits in a short time, and patients should be counseled accordingly.

Naltrexone should not be prescribed for patients with severe liver disease. High-dose naltrexone has been associated with irreversible increases in liver enzymes, although this is unlikely at recommended dosages. Nevertheless, liver enzymes should be checked at baseline and monitored periodically.

Extended-release injectable naltrexone (Vivitrol) is just as effective as the oral form7 and has the advantage of providing a steady blood level for 30 days. While most patients who want to recover from alcohol dependence are able to take a tablet daily, adherence can be an issue, as with any medication. The injectable regimen also ensures patients will return for monthly visits, which give the clinician the opportunity to monitor progress and address problems.

Because it blocks opioid receptors, naltrexone may prove useful in treating opioid dependence. However, the drug should not be given to those physically dependent on opioids, as it will precipitate severe withdrawal. It is contraindicated as well for patients who require or are likely to require opioid analgesia for medical indications.

Acamprosate (Campral) inhibits the release of glutamate, an excitatory neurotransmitter. Chronic alcohol use increases the number of glutamate receptors, and when alcohol is withdrawn, overactivity in this system is apparently responsible for persistent dysphoric effects and for some of the craving triggered by alcohol-associated cues.

Numerous studies have shown acamprosate to be effective,8 but its three-times-a-day dosing is a drawback. Evidence for its efficacy, particularly for the moderate alcoholics likely to be seen in primary-care practice, is less robust than for naltrexone.6

Diarrhea, the most common adverse effect of acamprosate, can usually be circumvented by starting at a low dose and titrating up slowly. The drug is eliminated through the kidneys and should be given at half-dosage to patients with renal insufficiency or avoided altogether.

Disulfiram (Antabuse) alters the metabolism of alcohol to cause a buildup of acetaldehyde, which may cause nausea and other unpleasant effects. Unlike other drugs for alcohol dependence, disulfiram does not address the neurobiologic aberration responsible for addiction or attenuate cravings or dysphoria associated with abstinence: it simply makes drinking unpleasant. Disulfiram is used far less now than it used to be. Unlike naltrexone and acamprosate, research suggests that disulfiram lacks long-term effectiveness9; many patients simply stop taking it. However, it may be helpful for patients who tend to drink impulsively and are strongly motivated. Disulfiram is most effective when given in a monitored fashion, such as in a clinic or by a spouse.

Topiramate (Topamax) has been shown to significantly improve drinking outcomes compared with placebo. During a recent 14-week trial, for example, topiramate significantly increased the proportion of volunteers with 28 consecutive days of abstinence or non-heavy drinking.10 The difference between topiramate and the placebo group was still diverging at the end of the trial, suggesting that its maximum effect had not been reached. In fact, researchers believe that the magnitude of topiramate's effect may be larger than that for naltrexone or acamprosate.

Follow-up and support

At the beginning of treatment, it is advisable to see patients at least monthly to inquire about symptoms, medication side effects, and positive changes, such as reduced craving. It is important not to focus on drinking as the sole clinical outcome, but to ask about other areas of the patient's life; we should recognize that if patients want to overcome alcohol dependence, it is because they have other goals and lack of progress toward these goals will weaken their resolve to avoid alcohol.

A key aspect of the clinician's role is helping patients identify and work toward all their goals. Clinicians should avoid telling patients what to do and instead join with them as partners in their journey toward abstinence. For patients who cannot identify goals other than abstinence, try asking what aspects of their lives they would like to continue unchanged, how they might like certain aspects of their lives to change, and what some of the benefits of not drinking might be. Help patients realize that drinking is interfering with their goals, not yours.11

Adherence and relapse. Strong rapport is invaluable. A powerful desire to resume drinking is one of the strongest predictors that the patient might stop taking medication. Establishing an open, nonjudgmental relationship makes it more likely that the patient will discuss these feelings with you and will not avoid you should there be a relapse.

This issue of relapse should be raised after patients commit to changing their drinking. I temper a sense of optimism with the caveat that backsliding may occur at some point and make it clear that in this eventuality we would simply sit down, figure out what happened, and work on what to do next. Patients are often very relieved to hear that that they don't have just one chance with you and that a relapse cannot be overcome.

Abstinence vs. controlled drinking. Some patients are unwilling to embrace abstinence as a goal and instead opt for reducing alcohol consumption to a manageable level. This is not ideal, but studies have shown that most patients who achieve remission from alcohol dependence did not set out to abstain completely, and a number of them never stop drinking entirely.12 Some therapies, in fact, may be more effective in preventing heavy drinking than maintaining abstinence.

For other patients, however, abstinence should be strongly encouraged, particularly those with liver disease and pancreatitis. Of course, pregnant women should abstain completely.

Summary

Alcohol dependence can be managed in primary-care settings just like other chronic conditions mediated by behavior—diabetes, hypertension, and heart disease. Early detection, mutual goal setting, appropriate pharmacotherapy, specialty referrals when necessary, frequent follow-up visits, a sense of optimism, and a collaborative partnership between patient and clinician often produce excellent outcomes and appreciative patients.

Dr. Brown is associate professor in the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health in Madison. He is also clinical director of the Wisconsin Initiative to Promote Healthy Lifestyles.

References

1. Manwell LB, Fleming MF, Johnson K, Barry KL. Tobacco, alcohol, and drug use in a primary care sample: 90-day prevalence and associated factors. J Addict Dis. 1998;17:67-81.

2. Higgins LA. Sobering stats invite insurers to fight alcoholism effectively.Managed Care. 2007;16(6):47-50.

3. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Available at: www.ahrq.gov/clinic. Accessed May 6, 2008.

4. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. Updated 2005 Edition. Available at: http://pubs.niaaa.nih.gov. Accessed May 6, 2008.

5. Williams R, Vinson DC. Validation of a single screening question for problem drinking. J Fam Pract. 2001;50:307-312.

6. Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295:2003-2017.

7. Garbutt JC, Kranzler HR, O'Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence; a randomized controlled trial. JAMA. 2005;293:1617-1625.

8. Mason BJ. Treatment of alcohol-dependent outpatients with acamprosate: a clinical review. J Clin Psychiatry. 2001;62 Suppl 20:42-48.

9. Fuller RK, Branchey L, Brightwell DR, et al. Disulfiram treatment of alcoholism. A Veterans Administration cooperative study. JAMA. 1986;256:1449-1455.

10. Johnson BA, Rosenthal N, Capece JA, et al. Topiramate for treating alcohol dependence; a randomized controlled trial. JAMA. 2007;298:1641-1651.

11. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed., New York: Guilford, 2002.

12. Brown RL, Saunders LA, Bobula JA, Lauster MH. Remission of alcohol disorders in primary care patients. Does diagnosis matter? J Fam Pract . 2000;49:522-528.

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