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Medications Can Aid Recovery from Alcoholism
by Paula Kurtzweil The number 13 represents bad luck for some people, but for Floyd McCrory of Rockville, Md., it's a sign of continuing good fortune. This year, he celebrates 13 years of sobriety. "Best thing I ever did," he said about quitting drinking. "It turned my whole life around." McCrory, 63, realized he was an alcoholic in 1983. That was the year he got so sick from alcohol-induced pancreatitis, he swore he'd never drink again. He went into a 28-day treatment program and now attends as many as 12 Alcoholics Anonymous meetings a week, he said. In addition, he serves as volunteer director of the Rockville (Md.) Metro Group. As director, he helps other people overcome their addiction to alcohol. He's rarely short of work because, according to the most recent estimates from the federal government's National Institute on Alcohol Abuse and Alcoholism, in 1992, 6.3 percent of men and 2.6 percent of women were alcoholics. That translates to nearly 8 million alcoholics in the United States. As many as 1.5 million of them seek treatment each year. Many follow McCrory's example: They enroll in inpatient and outpatient alcoholism treatment programs and supplement that with regular attendance at AA and other self-help group meetings. Others find success with AA and other self-help groups alone. Some turn to psychotherapy. Some quit drinking completely on their own. In some cases, recovering alcoholics are aided by two drugs specifically for treating alcoholism, one of which was approved by the Food and Drug Administration in December 1994. Like McCrory, many alcoholics who seek treatment find success-they learn to abstain totally from alcohol. But the majority-as many as 90 percent, according to NIAAA-relapse at least once during the four years following treatment. Fifty percent relapse within the first few months. Subsequent treatment attempts may or may not prove successful. What Is Alcoholism? Alcoholism is a complex disease with physical, social and psychological consequences-not only for alcoholics but also for people closest to them. In the past, alcoholism was often viewed as a moral weakness or character flaw; it was thought that the person could stop drinking if he or she really wanted to. It wasn't until 1970, with the establishment of NIAAA and a national public education effort, that people began to understand and accept that alcoholism is a life-threatening, chronic disease involving psychological and physical dependence on alcohol. Based on the American Psychiatric Association's 4th edition of Diagnostic and Statistical Manual of Mental Disorders, NIAAA recognizes four signs of alcoholism:
The APA manual distinguishes between alcoholism and alcohol abuse. The latter is a less severe problem; unlike alcoholics, alcohol abusers do not develop physical withdrawal or compulsive alcohol use. However, like alcoholics, their drinking has negative health, economic and social effects. Both alcoholics and alcohol abusers need treatment, although the goals differ. In most cases of alcohol abuse, the goal is to limit drinking, while for alcoholism, it is to stop drinking altogether. Why some people become alcoholics remains a mystery, although most scientists now agree that a combination of genetic and environmental factors increases a person's vulnerability. Based on the results of Swedish adoption studies, some researchers divide alcoholism into two types. Type I, the most common, occurs in both men and women and is associated with adult-onset alcohol dependence. This form, also known as "milieu-limited" alcoholism, appears to be the result of "genetic predisposition and environmental provocation," according to NIAAA's 1991 publication Alcohol Research: Promise for the Decade-that is, the development of alcoholism in these cases is an interaction between inherited predisposition and the person's life situations. Type II, or male-limited, alcoholism, on the other hand, is due mainly to genetics. It occurs only in men, usually with early onset in the teen years, and is more difficult to treat. Type II alcoholics tend to exhibit antisocial, aggressive behavior. A study in a 1992 Journal of Studies on Alcohol (Volume 53, Number 2) suggests there may be a third type similar to Type II but without the antisocial behavior. People often realize a friend or family member has alcoholism through the consequences of drinking, such as arrests for drunk driving or problems at work, including chronic absenteeism. Alcoholics' spouses may demand they leave the house. Later in the disease, they may be hospitalized for liver disease or pancreatitis. Denial of these and other negative effects of alcohol in their lives is common in alcoholics and those close to them, according to the National Council on Alcoholism and Drug Dependence. But sometimes the negative occurrences can serve as a catalyst for getting the alcoholic into treatment. More usually, an ultimatum from the spouse or other family member, boss, doctor, or judge is the driving force. McCrory sought treatment after his wife, son and daughter told him he needed help. A bout with acute pancreatitis (inflammation of the pancreas) also helped convince him. "The pains were so severe, I wanted to die," he said. "I never want to go through that again." Conventional Treatment For some alcoholics, treatment begins with "detoxification"-that is, medical management of acute alcohol withdrawal. This can be done in the hospital or on an outpatient basis and usually lasts one to seven days. FDA has approved two anti-anxiety drugs, Valium (diazepam) and Librium (chlordiazepoxide), for treating alcohol withdrawal effects. Some doctors also prescribe other drugs in the same chemical class, also approved to treat anxiety. These drugs help decrease the symptoms of alcohol withdrawal, including anxiety and tremors, and reduce the risk of serious consequences of withdrawal, such as seizure and delirium. Dosages are based on the severity of patients' symptoms. Use of these drugs beyond the withdrawal phase is not advised for alcoholics because of the drugs' abuse potential and alcoholics' addictive inclination. Because heavy drinking often results in nutritional deficiencies, vitamins, particularly thiamin and other B vitamins, also may be given. Once sober, patients can begin rehabilitation. Many enroll in hospital-based or freestanding alcoholism treatment centers. According to a 1991 survey by the U.S. Department of Health and Human Services, nearly 575,000 people were treated in 8,298 facilities in the United States on Sept. 30, 1991. Of those, 12 percent were treated as inpatients, 88 percent as outpatients. While enrolled, patients attend classes, hear lectures, and participate in individual, group and family counseling sessions. The activities aim to educate patients about alcoholism, help them recognize that they have the disease, and help them adjust to a life without alcohol. Patients often are introduced to self-help groups, such as AA. Family members often get involved, too, and may be referred to Al-Anon, a self-help group for family members of alcoholics. Following this intensive program, patients are often encouraged to continue with some type of aftercare program for at least one year. This might include AA, individual or group psychotherapy, or a center-sponsored program that continues on a smaller scale the same type of activities offered during the intensive treatment. For example, at an addiction treatment center in Bethesda, Md., aftercare consists of a 15-week program, in which participants meet twice a week for one hour. They hear lectures and participate in group therapy. This is followed by ongoing group therapy of up to one year for patients with a history of relapse. "This is a powerful enough disease that a great number of people are going to [drink] one more time, at least," said Larry Goodwin, a licensed social worker and director of the Addiction Treatment Center at Montgomery General Hospital in Olney, Md. "And sometimes that's a necessary part because they find out, 'I don't like the results. I've tried it again, and [the experts] are right.'" Drug Treatment Alcoholics also may be helped in their recovery with one of two drugs approved for discouraging alcohol intake. Antabuse (disulfiram), sold by Wyeth-Ayerst Laboratories Division, has been marketed since 1948. When combined with alcohol, even small amounts, this drug causes unpleasant effects, such as facial flushing, throbbing headache, nausea, vomiting, and increased blood pressure and heart rate. The drug's effectiveness depends on patient motivation. Those who want to drink simply stop taking the drug. A 1986 study found that Antabuse did not improve abstinence rates, length of time to relapse, or psychosocial functioning any more than counseling alone. But, patients on Antabuse who continued to drink drank less frequently than relapsed patients who did not receive the medication. The second drug, ReVia (naltrexone), approved by FDA in December 1994 for treating alcoholism, acts on the opioid receptor in the brain to help prevent relapse and reduce alcohol cravings in those who drink. ReVia was developed by The DuPont Merck Pharmaceutical Co., which previously marketed naltrexone under the trade name Trexan for treating narcotic dependency. The drug remains available for treating narcotic dependency but under the new brand name, ReVia. In a 12-week study of 70 alcoholic men, 23 percent of the ReVia-treated patients relapsed, compared with 54 percent of those receiving placebo. Of those who drank during the study, 50 percent of those on ReVia relapsed to heavy drinking, compared with 95 percent of those receiving placebo. A study of 104 alcoholic men and women found that patients who took ReVia were about twice as successful in quitting drinking as patients who received placebo. However, because ReVia was tested in conjunction with supportive therapy, FDA approved its use only as an adjunct to supportive therapy (such as group therapy) in treating alcoholism. Studies show the drug is nonaddictive. But it can cause liver toxicity when given at doses higher than recommended. Therefore, it is not recommended for people with active hepatitis and other liver diseases. NIAAA is sponsoring additional studies to determine which patients are best suited for treatment with ReVia, as well as what dose, therapy combinations, and treatment duration work best. Research Continues Though treatments are helping make controlling alcoholism easier, a cure is more elusive. The disease is so complex, said Richard Fuller, M.D., director of NIAAA's division of clinical and prevention research, that it may be unlikely one single drug to treat alcoholism will be discovered. Instead, he said, research will continue to focus on finding drugs that can treat various aspects of alcoholism. "I really see alcoholism as a chronic relapsing disease, like arthritis," he said. "And just as with arthritis, in which various inflammatory agents can be used to treat an acute episode, there will be more drugs developed to help alcoholics get and stay on the road to recovery." Current NIAAA research efforts focus on developing drugs to:
One person who is a firm believer in such programs is AA member McCrory. "These people have been there," he said. "They tell it like it is: Alcoholism will never be cured, but there will be good days and good times if you stay sober." Paula Kurtzweil is a member of FDA's public affairs staff.
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