Why Aren’t Physicians Approaching Alcohol Use Disorder Like a Medical Disease?

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Addiction is a complex disorder and, unless one specializes in it, they typically aren’t aware of current medical breakthroughs.

There are several theories about how to approach alcohol use disorder. Harm Reduction, SMART Recovery®, and Alcoholics Anonymous, for example, all are approaches that use different techniques and philosophies. These three groups encompass the majority of thought about alcohol use disorder treatment and from them comes the recommendations of treatment that physicians typically follow. Ironically, none of these groups embrace a holistic approach of pharmacological solutions in combination with therapy and other treatments. While the Harm Reduction community is by far the most tolerant of pharmacological solutions of any of the recovery movements, many in the Harm Reduction movement are still reluctant to utilize pharmaceutical options until after therapy has proven ineffective. Among these movements, Alcoholics Anonymous is the most intolerant towards medications. In fact, a survey conducted by the Journal of Alcohol Studies in 2000 found that out of a random sample of 277 members, 29% of them were directly pressured by AA members to go off their medication. The study also found that the more frequently Alcoholics Anonymous meetings were attended, the less likely AA members were to view medication as a positive treatment option. As Alcoholics Anonymous is the leading model for addiction treatment, this obviously shapes national recommendations that primary care physicians follow. Since primary care physicians typically are not up to date with the latest advancements in addiction treatment, they simply default to recommending AA as the solution for AUD rather than another more effective treatment. Most simply aren’t aware another solution exists.

Addiction is a complex disorder and unless one specializes in it, they typically aren’t aware of current medical breakthroughs. As well, many in the addiction treatment community are opposed to the idea of medical advancement since it directly obstructs their personal treatment philosophy and may directly affect their pocketbooks. A perfect example of this is the inpatient treatment institution or the rehab. It has been proven across several studies that inpatient treatment offers no better long-term outcomes than outpatient treatment, yet it is still pushed as the primary model of treatment and is several times more expensive. A part of the problem is simply that many are financially incentivized towards more expensive solutions rather than focusing on best patient outcomes and the majority of primary care physicians simply don’t know any better. It just so happens that in the case of addiction treatment, the cost is not a reliable guide of what is best for patient care.

As an epidemiologist, my mission is to determine the best course of action to treat a population. I am personally astounded by the recovery community’s general lack of epidemiological guidance when developing drug and alcohol treatment programs for public health. Oddly enough, drug and alcohol addiction is the one area of medicine in which epidemiologists do not spearhead the public treatment of a medical problem. The efficacy of drug treatment programs in America is low, embarrassingly low. In fact, the (conservatively estimated) $70 billion treatment industry is lucky to demonstrate any efficacy at all. This has been the case since the emergence of the inpatient rehab in the 1980s, and since rehab treatment models have remained static since that time, recovery rates have not improved significantly either.

Compare this with epidemiological efforts to combat nicotine addiction, these results present a stark contrast. Abstinence rates for nicotine are at an all-time high of 82% in the United States according to the Center for Disease Control.

Epidemiological nicotine addiction treatment has been the only drug program to have significantly impacted drug use in a free society in recorded history. So what do epidemiologists do right that the drug rehabilitation industry is currently doing wrong?
The answer is pharmacological assistance in quitting addiction and treating addiction as a medical problem. Let me say it again: Medication is a vital key in helping a population quit addiction. Let’s look at nicotine addiction: it is very widely known and well accepted that nicotine is one of most addictive drugs ever encountered. Faced with such an addictive drug, how is it possible that epidemiologists were able to move the needle in smoking rates? The answer is that they embraced a medical-psycho-social model of recovery.

A comprehensive study from the Western Journal of Medicine in 2002 found that from over 6,000 articles on nicotine cessation, two conclusions emerged.

  • The first was that taking FDA-approved medication for nicotine cessation more than doubled the likelihood of quitting smoking.
  • The second conclusion was that this likelihood was increased even further by coupling anti-smoking medication with evidence-based therapy for behavioral modification.

Knowing that FDA-approved anti-addiction medication works for smoking, and that anti-addiction medication coupled with therapy works even better, one wonders why the FDA hasn’t approved medication for those with alcohol use disorder? In fact, they have, and these medications are very likely the ones that your counselor, sponsor, or physician isn’t telling you about. In fact, the majority of the rehabs in the United States do not use any of this medication despite charging an astounding $30,000-$80,000 for 30 inpatient days. Neither therapy methods alone nor 12-steps alone work nearly as effectively as therapy plus medication. No study in existence shows therapy or 12-step involvement to be as effective as a combined therapy and medication program.

So what are these FDA approved medications and how effective are they? The FDA has approved two different medications for use with alcohol use disorder. The first is acamprosate (Campral is the brand name). Acamprosate has been in use since the 1980s for alcohol use disorder treatment in Europe and was accepted by the FDA in 2004. It functions in a number of ways to correct chronic drinking in the brain, but its primary function is to correct initial depression that alcoholics get when they first quit drinking and reduce cravings by inhibiting receptors that alcohol up-regulates. In layman’s terms, it calms the feelings of restlessness, irritability, and discontent that alcoholics experience when they first quit drinking. Acamprosate is meant to be taken daily for the first 12 months of abstinence. This means that while this drug is effective in helping to achieve abstinence, the patient must utilize tools along with the medication and commit to the idea of abstinence as a lifestyle.

drug rehabs knoxville tnThe second medication is Naltrexone. Naltrexone is an opioid inhibitor that has been FDA approved as a constant low dose (daily intake) or as a supplement prior to drinking. If the goal is abstinence, this drug can serve two purposes. In chronic alcoholics, a constant low dose inhibitor may stop the immediate cravings for alcohol although long-term use of daily intake, monthly injections, or implants may actually up-regulate the opioid system resulting in worse relapses after the patient is taken off the medication if they are on it for too long. Naltrexone can also be used as an emergency relapse drug after acute care to reduce relapse if the patient feels compelled to drink. Patients, prior to relapse, have taken this drug and reported significantly lower impact of their relapse. In fact, naltrexone works so well to reduce relapse that many alcoholics use it to successfully drink on a regular basis with very few reports of high binge drinking. For acute care, at the beginning of treatment, constant low-dose naltrexone in combination with acamprosate and therapy have been reported to have the highest outcomes for abstinence-based treatment of any program at 67% after six months. Ironically, naltrexone is reported to have even better outcomes for patients who actually drink. A whopping 78% of patients who drink while on naltrexone succeed in controlling their drinking with no lapses into hard binging, and if the injectable form, Vivitrol, is used for chronic daily alcoholic drinkers, that success rate jumps to an incredible 93% given the patient can stay abstinent for the first week of treatment and therapy.

The combination of acamprosate plus naltrexone and cognitive-behavioral therapy currently shows the highest rates of recovery of any system in clinical trials for abstinence and naltrexone alone shows the best outcomes of any treatment program provided the patient chooses to moderate their drinking. No other program, not Alcoholics Anonymous, nor SMART Recovery®, nor psychological counseling comes close to achieving these rates of abstinence, yet hardly any treatment program in the country is engaging in this practice.

So why aren’t rehabs engaging in treating alcohol use disorder as a disease and giving patients appropriate medication? The answer is, if you are on these medications, you simply do not require inpatient treatment. Naltrexone even blocks the ability to get high for opiate users, so inpatient rehabs aren’t necessary since the patient isn’t at risk for relapse. If the patient drinks on naltrexone, the medication causes the body to react in such a way, that the next binge will be less and less until they are either drinking normally or have quit altogether. 40% of patients who drank on naltrexone simply quit drinking after six months while only 8% had that as an objective in their first week. Thus, the need for inpatient stays has simply become obsolete for alcohol and opiates users. Current evidence also shows naltrexone has an improvement for both meth and cocaine users as well. Strikingly, one then can conclude that inpatient rehabs are literally incentivized against advertising or discussing such options and most don’t unless it is deemed an extreme case.

Furthermore, the administration of such drugs can be a complex decision, particularly with patients who have developed liver problems, need anti-depressant medication, or need therapy for trauma, which is the majority of AUD patients. So even those primary care physicians who would entertain the idea of utilizing such drugs, most would prefer to refer the administration to an addiction specialist. Hence, the ideal situation for optimal patient care is an outpatient clinic that has no inpatient rehab attached to it. These clinics are just now in their infancy, discovering their place in addiction treatment as the model for the 21st century. With the use of such drugs, outpatient administration of medication assistance along with therapy can offer patients optimal outcomes with minimal costs.

So primary care physicians have not previously viewed AUD as a condition to be treated like a medical disorder simply because they did not have the option to do so. Now with new breakthroughs in medication and combination therapies, physicians may be referring patients to outpatient medical centers more commonly than inpatient rehabs. Already, the inpatient model of treatment for drug and alcohol addiction is obsolete in those areas of the country where a outpatient medical center can offer such services.

Author: Matthew Leichter

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