Behavioral therapies plus pharmacotherapies can add up to success

November 14, 2001

There is no singular approach to treating alcoholism. Treatment professionals can choose from an array of behavioral therapies and pharmacotherapies. However, behavioral therapies may have limited effectiveness because they do not address underlying brain processes at the neurotransmitter level.

Conversely, pharmacotherapies may have limited success because they do not address the individual's need to develop coping skills, confidence about staying abstinent in risky situations, and the appropriate responses to high-risk stimuli. A study in the November issue of Alcoholism: Clinical & Experimental Research combines elements from both approaches - naltrexone (ReVia™), communication skills training (CST), and cue exposure combined with urge-specific coping skills training (CET) - into a comprehensive program and then assesses its effectiveness.

"It is generally recognized that a pharmacotherapy should not be used alone without providing some behavioral treatment or counseling," said Peter M. Monti, professor of medical sciences and director of the Center for Alcohol and Addiction Studies at Brown University, and lead author of the paper. "However, behavioral treatments are often used without pharmacotherapy for alcoholism. The usual reasons are that the patient does not want to use a medication, the counselor or treatment program does not believe that the medication would be useful for the patient, or the patient is not eligible for the medication for medical reasons."

In this study, researchers looked at the effects of prescribing naltrexone versus a placebo during the 90 days after alcoholics completed a two-week daily alcohol treatment program. The two-week program consisted of either CST/CET training, or educational discussions and relaxation training.

"Alcoholics who took naltrexone for at least two months of the 90 days that they were prescribed it drank alcohol significantly less heavily as compared to alcoholics who were given a placebo," said Monti. "While naltrexone did not affect whether alcoholics had any drinks at all, alcoholics using naltrexone had fewer heavy drinking days, had fewer drinks if they drank, and had fewer urges to drink. The beneficial effects of naltrexone lasted only while the alcoholics were taking naltrexone, suggesting that it would be helpful to prescribe naltrexone for longer than 90 days."

Naltrexone has been used for the treatment of alcoholism since its 1994 approval by the federal Food and Drug Administration. Naltrexone acts as an opioid antagonist within the opioid neurotransmitter system, which is a part of the brain's reward system. When opioids are stimulated, levels of a neurotransmitter called dopamine are increased. Dopamine activity is thought to be key to experiencing the "high" of a variety of different drugs, including alcohol. Naltrexone achieves its effects by "blocking" this domino-type chain of events that lead to the desire to continue drinking. In short, naltrexone decreases the rewarding effects of drinking and reduces the craving for alcohol that often leads people to relapse.

"One thing that is new about this study," said Stephanie S. O'Malley, professor of psychiatry at Yale University School of Medicine, "is the sequencing of therapies. The behavioral interventions were provided during day hospital treatment, while the pharamcotherapy occurred after discharge when the patient had brief contacts with a physician for 12 weeks. The results suggest that naltrexone may be a useful aftercare strategy that, in conjunction with new communication skills and strategies for coping with urges, will help patients maintain their improvements in the long term."

Patients who received the communications, cue exposure and coping skills training were significantly less likely to report a relapse day than patients who received the education/relaxation training. Furthermore, CST/CET patients also reported fewer heavy drinking days at six- and 12-month assessments.

"Alcoholics who received about five sessions of skills training as part of their two-week intensive alcohol treatment program had better treatment outcomes during the following year than did the alcoholics who received the same intensive treatment but without the skills training," noted Monti. "This means that even a few sessions of skills training added to alcohol treatment programs can result in lasting benefits."

CST is designed to help alcoholics develop more healthy social networks in order to make relapse to drinking less likely. This is necessary for primarily two reasons: alcoholics often damage their family relationships, and many of their friends also drink heavily. Alcoholics are taught communications and conversation skills that can be used to improve their close relationships, such as learning to accept criticism and resolve conflicts gracefully, and to increase their sober friendships.

CET is designed to help alcoholics practice 'bringing down' the urge to drink when they are in high-risk situations. For example, patients practice thinking about specific effects that sobriety would have for them (such as spending more time with their children), and by thinking of specific things they could do to minimize the urge to drink (such as calling a sober friend or playing basketball).

These methods are individualized for each person's needs, as a method that works for well for one person might not work as well for another person. Many treatment programs currently use some form of coping skills training, and to a lesser degree communication skills training, however, the cue exposure treatment approach is not currently used in the United States.

O'Malley said one reason for hesitation might be the very novel approach of some CET components. "Specifically," she said, "one component of the CET involved having the person pour a glass of their most frequently consumed alcoholic beverage and then think about the aspects of the beverage that increased their urge to drink.

They were then taught a new coping strategy for dealing with this urge. While this is probably a very powerful method, I suspect few programs, except the most innovative, use this technique at present. Other components, however, have some parallels to interventions already incorporated into some programs. Specifically, the person was asked to imagine a situation in which they had felt like drinking in their past, and to use one of the tools that they had learned to help 'bring down' their urge to drink. This approach could be readily implemented in most programs."

"These results provide additional evidence that naltrexone can have a beneficial effect in reducing the severity of relapses among alcoholics who continue to take it," said Monti.

"The results also provide evidence that even four or five sessions of coping skills training, when part of intensive alcohol treatment, can have lasting benefits for preventing relapse and reducing relapse severity. "The success of training alcoholics to use a variety of skills suggested by social learning theory warrants further study to find ways to improve outcomes even more. In particular, it would be useful to know more about which skills are more useful to teach, and which are less useful to patients. Clearly, the skills training approach is one of the more beneficial approaches to treating alcoholics."
-end-
Co-authors of the Alcoholism: Clinical & Experimental Research paper included: Damaris J. Rohsenow and Robert M. Swift of the Providence VA Medical Center and the Center for Alcohol and Addictions Studies at Brown University; Suzy B. Gulliver, Suzanne M. Colby and Marilyn K. Asher of the Center for Alcohol and Addictions Studies at Brown University; Timothy I. Mueller, Richard A. Brown and Alan Gordon of Butler Hospital/Brown University; and David B. Abrams and Raymond S. Niaura of Butler Hospital/Brown University School of Medicine.

The study was funded by the National Institute on Alcohol Abuse and Alcoholism, and the Department of Veterans Affairs.

Alcoholism: Clinical & Experimental Research

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