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WHEN it
comes to treatment, the experts think alcoholism needs
to catch up to depression. Three decades ago, long
before the dawn of the Prozac Era, depression was a
disease rarely treated in its mild form, reluctantly
treated with drugs and usually treated by experts only.
Today signs of depression are actively sought, drugs are
prescribed early and often, and most cases are handled
by nonpsychiatrists.
With
alcohol abuse, however, most physicians don’t go looking
for trouble and don’t recognize it until it’s breathing
in their face. Overdrinking patients often don’t think
of looking for help even if they know they are heading
in the wrong direction. And society as a rule looks at
alcohol treatment as a last-chance, 90-degree corner
taken only at high speed.
All this
will change if American physicians adopt the new
guidelines for “Helping Patients Who Drink Too Much”
promulgated by the National Institute on Alcohol Abuse
and Alcoholism (NIAAA), part of the National Institutes
of Health.
The idea
is to simplify the screening for excessive alcohol use
in general medical practice and to convince clinicians
and patients that early intervention for drinking that
hasn’t yet wreaked havoc is both possible and useful.
“We’re
trying to increase the accessibility and attractiveness
of treatment to a much broader spectrum of people,” said
Mark L. Willenbring, a psychiatrist who directs the
Division of Treatment and Recovery Research at NIAAA.
Those especially targeted in the guidelines are heavy
drinkers who are not yet physically dependent on alcohol
but are at risk for becoming so.
“We know
that that group responds very, very well to what we call
facilitated self-change and brief motivational
counseling. We could make that very widely available
without much cost,” Willenbring said.
A big
part of the new strategy is to make primary-care
physicians—people without specialized training in
addiction medicine—think about alcohol abuse the way
many now think about depression, anxiety and
obsessive-compulsive disorder. Which is to say, they
need to think of it as something common, diagnosable and
within their capacity to treat. The guidelines make this
easy: The screening tool for alcohol problems consists
of a single question. For men: How many days in the past
year have you had five or more drinks? For women: How
many days in the past year have you had four or more
drinks?
“Most
doctors don’t know how to make the diagnosis and don’t
really try to do anything about it until it is so easy
to diagnose that all you have to do is glance at the
patient,” said Charles O’Brien, a professor of
psychiatry at the University of Pennsylvania who has
been treating alcoholics for 38 years.
“It used
to be said that you can’t treat somebody until they are
down and out. But when they are down and out, they are
really hard to treat,” O’Brien said.
Willenbring concurs.
“I think
there is a belief that people with more moderate levels
of dependence don’t know they have a problem. I think
they do. But they don’t think rehab is the model of
treatment for them—and I don’t, either.”
The sort
of therapy both advocate does not involve magic bullets
or easy answers or effortless behavior change. But it
does enlist pills that help a little, quite a bit of
talk and lots of self-discipline.
And what
does it get a person?
Perhaps
not surprisingly, there’s evidence that getting control
of a drinking problem early can improve one’s health,
completely apart from the social, psychological and
familial benefits it brings.
Two
drugs that have been enlisted in helping in the battle
against alcohol abuse or dependence are naltrexone,
which blocks opiate receptors in the brain that are
involved in alcohol’s “reward pathways,” and acamprosate,
which works through so-called Gaba receptors to decrease
the anxiety and restlessness that can come with
abstinence.
Abstinence, in almost all practitioners’ minds, is
always the goal. But its absence doesn’t signal abject
failure.
“It is a
fiction that the typical change process is a sudden
transformation,” Willenbring said. “The more common is a
change process that lasts years and is characterized by
lengthening periods of sobriety and shorter relapses
until they are gone.”
In that
way, alcohol abuse is like depression. In another way,
too.
“Recovery from depression requires effort. The same is
true for alcohol dependence,” he said. And in both
cases, he thinks they’re really worth the effort. |
