Therapeutic Modalities: Nonpharmacological

A variety of therapeutic modalities are used within the context of outpatient and residential treatment ser­vices, and many programs use a combination of these interventions. The approaches with the greatest amount of supporting evidence are behavior therapy, group ther­apy, family treatment, and motivational enhancement (Edwards et al, 2003). Behavior therapists stress the importance of teaching new, adaptive skills designed to alter the conditions that precipitate and reinforce drink­ing.

One example of this approach is relapse prevention, which focuses on coping with situations that represent high risk for heavy drinking. Research also indicates that Twelve Step Facilitation, which is designed to introduce problem drinkers to the principles of Alcoholics Anony­mous, is as effective as more theory-based therapies.

Therapeutic Modalities: Pharmacological. There are three kinds of pharmacotherapy for persons with alcohol dependence: Alcohol-sensitizing drugs, medications to directly reduce drinking, and medications to treat comorbid psychopathology (Kranzler, 2000). Alcohol-sensitizing drugs such as disulfiram and calcium carbimide cause an unpleasant reaction when combined with alcohol.

Although these drugs may help alcohol- dependent persons when special efforts are made to ensure compliance, their efficacy in the prevention or limitation of relapse has not been demonstrated. Several approaches to enhancing voluntary compliance with disulfiram ther­apy have been evaluated, such as the use of incentives, and enlisting the help of family members. Under these condi­tions, disulfiram can significantly increase the number of abstinent days and decrease total drinks consumed.

In contrast to drugs like disulfiram that precipitate an aversive reaction following drinking, another class of medications has been developed to reduce drinking and prevent relapse by operating on the specific brain neuro­transmitter systems implicated in the control of alcohol consumption, including endogenous opioids, catechola­mines (especially dopamine), and serotonin.

Based on research suggesting that opioid antagonists, such as nal­trexone, decrease ethanol consumption in laboratory animals and humans, a series of double-blind, placebo- controlled trials have been conducted with alcohol- dependent patients. In general, naltrexone has been found to be superior to placebo in delaying the time to relapse and reducing the rate of relapse to heavy drinking among patients (Kranzler and Van Kirk, 2001). The most comprehensive clinical trial of naltrexone therapy was conducted at 11 U.S. sites with nearly 1400 patients (Anton et al., 2006).

Naltrexone was associated with more abstinent days and reduced the risk of a heavy drinking day after a relapse. The effects, however, tended to be short-lived, with no advantage evident 1 year later after medication had been suspended. The findings open the possibility that naltrexone with medical management may be delivered by primary care clinicians as an alternative to traditional alcohol treatment programs. Another focus of medications research has been Acamprosate, an amino acid derivative.

Multicenter studies conducted in a variety of countries have shown significant advantages for acam- prosate over placebo, but other large-scale studies have been negative (Kranzler and Van Kirk 2001; Anton et al, 2006). In summary, despite advances in the search for a pharmacological intervention that could reduce craving and other precipitants of relapse, the additive effects of pharmacotherapies have been marginal beyond standard counseling and behavior therapies.

Because psychiatric disorders may contribute to the development or maintenance of heavy drinking, it is generally believed that the treatment of psychiatric comorbidity may have beneficial effects on drinking out­comes. Subsequent to detoxification, many patients with alcohol dependence complain of persistent depression, anxiety, insomnia, and negative emotional states, includ­ing frustration and anger.

These symptoms may last for weeks or months, and they may contribute to relapse. Although most instances of postwithdrawal depression and anxiety will spontaneously remit within a few days to several weeks, there are still substantial numbers of patients whose severe and persistent psychiatric symp­toms may require treatment. In many cases antidepres­sants, such as the selective serotonin reuptake inhibitor fluoxetine, and nonbenzodiazepine anxiolytics, may treat the co-occurring disorder and also have a beneficial effect on treatment outcomes for alcohol use (Kranzler, 2000).