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Alcohol dependence treatment: Facilitating the process of change with medications
Welcome to the first in a series of six articles designed to provide you with the latest information on the use of medications in alcohol dependence treatment. Medications (pharmacotherapy) used as adjuncts to counseling techniques and biopsychosocial, educational, and spiritual therapies are an increasingly important part of a comprehensive treatment approach for alcohol dependence. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) demonstrated this trend in its 2005 guidelines, which recommend that all FDA-approved medications be considered when treating individuals who have active alcohol dependence or who have stopped drinking recently but are experiencing cravings or slips.
The addiction counseling community needs to understand how these medications are used in order to optimally coordinate care of patients with other treatment providers. Thus, the article series Pharmacotherapy: Integrating New Tools Into Practice will not only provide the latest efficacy and safety data on these medications, it will also explore how we can build better relationships among addiction professionals and medication prescribers. Additionally, clinical case studies and how these relate to the treatment planning process will be discussed. The series will also examine the current barriers to medication use in treatment while offering potential solutions. Finally, the series will discuss specific instances of how medication can be used in typical alcohol-dependent individuals.
The series begins with an article by Carlo DiClemente, PhD, who discusses recovery from alcohol dependence as a process of behavioral change requiring work between the addicted individual and treatment providers using established psychosocial therapies. DiClemente examines how medications may complement counseling and facilitate that process of change, and he cautions against the potential drawbacks of medication use, especially if used improperly.
Anyone who has treated addictions understands the challenges facing the addicted individual and the treatment provider, due to the sheer number of factors affecting why and how individuals become addicted and manage recovery. Numerous models of addiction have been proposed, including the more integrative bio-psycho-social-spiritual model, whose lengthy name reflects the variety and scope of factors that clinicians must take into consideration during treatment. Genetics, personality, family and social influences, and spirituality can all play a role in the process of recovery. How can we clinicians put these influences into a perspective that allows us to understand how individuals cope with and overcome addiction? The answer is to understand better how patients change their addictive behavior.Several years ago, Dr. James O. Prochaska and I developed the Transtheoretical Model of Change,1 which characterizes intentional behavioral change as a process consisting of a series of stages through which patients can progress, regress, or recycle and which represent critical tasks that need to be accomplished to achieve sustained change. These stages are precontemplation, contemplation, preparation, action, maintenance, and relapse.
Precontemplation describes an individual's state in which there is little or no thought or interest in changing a behavior. For example, many alcohol-dependent individuals begin here, having no desire to stop drinking. In contemplation, the risks and benefits of change are assessed by the individual as part of decision making. At the preparation stage, an individual gets ready to change and tests the waters, gathering enough commitment to implement the action plan until the act of practicing the new behavior is taken. Maintenance is the stage where individuals stay committed to the behavioral change and integrate it into a new lifestyle. For many, however, action and maintenance are difficult, and relapse, which describes a return to the old behavior, may occur.
These stages of change can help clinicians better understand where a patient is and what they need to do in the process of recovery from addiction.2 Each stage presents unique challenges to treatment, and some of our treatment techniques are better suited for helping patients in one stage than in another. But if we consider all the various bio-psycho-social-spiritual elements that are part of the addiction in the context of these different stages, we have a better chance of helping patients to move from motivation to executing a behavior change—and sustaining that change.
Tools for change
Since the conceptualization of the stages, a number of new tools have been developed to assist clinicians in promoting movement through the stages of change for alcohol-dependent patients. New psychosocial therapies, such as motivational interviewing, have been developed. And, in addition to disulfiram, we now have three other medications approved by the FDA to treat alcohol dependence: oral naltrexone, acamprosate, and extended-release naltrexone (an intramuscular injectable formulation given once a month). However, these approaches and medications are not yet part of some clinicians’ practice, perhaps because of their comparative newness or possibly because medication use for alcohol dependence treatment is not consistent with some clinicians’ treatment philosophies.
Ultimately, the motivation to change behavior comes from the individual; as clinicians, we can merely enhance that motivation or hinder it. However, medications are important tools for clinicians; they have been shown to improve drinking outcomes (reducing heavy drinking, and promoting and supporting abstinence) when combined with psychosocial therapies.3, 4 Their efficacy is predicated on their being used as adjuncts to counseling in a multidisciplinary approach to treatment, rather than alone.
Medication cannot replace the knowledge and skills developed and fostered through work in mutual help groups and psychosocial therapy. These skills are the basis for the sustained behavioral changes necessary for a full recovery. But, if used properly, pharmacotherapy can help individuals in their process of change. Understanding how all interventions, including medications, can affect the stages and processes of change is important for clinicians.5 Determining how medications can be integrated into treatment is a special challenge for clinicians who may not be familiar with their use.
It is important to understand the different ways medication can potentially interact with the process of change. For those in precontemplation, knowing that there is the possibility of a helpful medication may create an interest in treatment and offer hope, triggering a move into contemplation. For those in contemplation, medication may promote consideration of the possibility of sobriety and support the idea that change is possible, since medications can be viewed by patients as another tool to help them achieve their goals. For example, Gastfriend and colleagues interviewed a large number of alcohol-dependent patients and found that they viewed extended-release naltrexone as potentially helpful in their efforts to change their drinking and achieve abstinence.6 It is notable that 73% of participants in the survey had never sought treatment for alcohol problems. Providing preparation-stage patients with additional treatment options, such as medications, offers them an opportunity to include these options when actively engaged in formulating their treatment plans. Moreover, a medication schedule and regimen may promote commitment to the plan and help in setting a time frame in which action will be initiated.
Once action to change drinking occurs, medication can support the steps taken by the patient and reinforce any initial success patients have in their efforts to stop drinking. For example, rapidly experienced positive effects from medications could encourage patients to strive for continued success. A study of extended-release naltrexone has shown a significant reduction in heavy drinking compared with placebo by the third day after injection 7; this significant reduction persisted over the entire duration of the six-month study. Medication also may eliminate some of the physical manifestations of dependence, which become stronger when drinking stops and often contribute to relapse.
Carlo C. DiClemente, PhD, ABPP For example, naltrexone (oral and injectable formulations) blocks opioid receptors in the brain, which reduces the euphoric effects associated with alcohol and may help reduce craving for alcohol. Patients dependent on alcohol also usually suffer from acute and protracted effects of withdrawal when they stop drinking. Acamprosate may help restore the balance of excitatory and inhibitory neurotransmitters in the brain and reduce the negative emotional affect, irritability, and other symptoms characteristic of protracted withdrawal. By reducing or eliminating the physical obstacles patients face during recovery, medications may improve the likelihood of their success.
The act of taking medication and following a dosing schedule demonstrates dedication to treatment, and this regimen may help support continued commitment to change. By reducing relapse to heavy drinking or any drinking in alcohol-dependent patients, naltrexone and acamprosate may also increase the chances of patients’ maintaining nondrinking behavior over time. In addition, it is a logical assumption that patients who have achieved medication-assisted sobriety will have a better chance of maximizing skill development through psychosocial therapy. Nevertheless, while medications may help achieve behavior change, it is important that the patient participate in the process and make the necessary adjustments to achieve sustained recovery and develop a strong sense of self-efficacy.
Potential medication drawbacks
Looking closely at all the potential effects of medication, it is also possible to see how medication could actually undermine the process of change if not used properly. An individual who is achieving success with medication conceivably might develop the misconception that medication alone is taking care of his or her drinking, and psychosocial therapy or mutual-help is no longer necessary. In this scenario, sustained abstinence would be unlikely after the discontinuation of medication, because the intentional process of change has been halted and the more complete behavior change process may not have been fully developed in the absence of counseling.
However, in one of the few studies examining the effect of medication on rates of participation in counseling, Zweben and colleagues found that medication does not have to have the unintended consequence of interrupting vital counseling. They found that patients receiving medication were just as likely, if not more likely, to attend mutual self-help groups and other counseling sessions as patients receiving placebo were.8
Other medication factors could also hinder the process of change. Adverse effects from medications may dissuade some patients from continuing with not only the medication but also other needed actions. Fortunately, the approved medications for alcohol dependence treatment have generally mild side effects, with the exception of the intended effect of disulfiram, which discourages drinking by deliberately producing toxic effects in patients when they drink alcohol. Still, all medications can produce adverse events, which may limit adherence to them and discourage patients from continuing with all treatments, including counseling and psychosocial therapy.
Adherence is always an issue with medications, and if medications take a long time to yield positive returns, patients may prematurely give up on them. Also, medications that have multiple or complicated dosing schedules may make adherence to treatment less likely. In fact, the rationale behind a drug such as extended-release naltrexone, which patients receive once a month, is to remove the need for a daily decision by individuals who may struggle with temptation and the decision to drink or not.
Summary
Providing patients with choices in treatment helps their commitment to change and is vital for long-term success. Counselors should include all the potential tools to assist drinkers in their treatment toolbox, so we should explore medications as another option to assist our alcohol-dependent patients. The key is ensuring that our tools fit into the process of change and the needs of the patients.
Of course, there are challenges to using medications, not the least of which is educating providers as to how medications can be used collaboratively with other treatment techniques. Understanding the rationale, purpose, goals, and timing of medication use in alcohol dependence treatment is critical to maximizing its benefits. Some of these issues require more study and clarification. While we may not understand completely how medications and psychosocial treatments interact with each other, we do know that medications should be used in combination with psychosocial therapies and not as a replacement for them, since studies clearly demonstrate the benefits of combined use of medications with these treatments.
The journey of recovery is influenced by a number of factors, as described in the bio-psycho-social-spiritual model. We need to assess these factors in each of our alcohol-dependent patients in order to understand what role misuse of alcohol has played in their lives and how we can best assist them. If we examine and understand recovery as a series of stages through which patients change their behaviors, we can better understand how pharmacotherapy can influence and positively impact that process of change. It takes time and effort for patients to get the process of change right, and often patients need multiple attempts and various types of treatments. Using medications properly and wisely is a new challenge that merits our attention and understanding so that we can best serve our patients.
Carlo C. DiClemente, PhD, ABPP, is a Professor in the Department of Psychology at the University of Maryland Baltimore County.References
- Prochaska J, DiClemente C The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood Ill:Dow Jones-Irwin; 1984.
- DiClemente CC. Addiction and Change: How Addictions Develop and Addicted People Recover. New York City:The Guilford Press; 2003.
- Bouza C, Magro A Munoz A, et al.. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review. Addiction 2004; 99:811-28.
- Garbutt JC, Kranzler HR O’Malley SS, et al.. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA 2005; 293:1617-25.
- Velasquez MM, Maurer GG Crouch C, et al.. Group Treatment for Substance Abuse: A Stages of Change Therapy Manual. New York City:The Guilford Press; 2001.
- Gastfriend DR, Chase KA, Carreras IE, et al. Attitudes of Potential Patients Towards an Innovative Pharmacotherapy for Alcohol Dependence. Presented at AAAP 2005 Annual Meeting and Symposium, Dec. 8-11, 2005, Scottsdale, Ariz. Abstract #20.
- Ciraulo D, Pettinati HM, Dong Q, et al. Early Onset of Effect of Injectable Extended-Release Naltrexone (XR-NTX) Pharmacotherapy for Alcohol Dependence. Presented at American Society of Addiction Medicine meeting, Oct. 26-28, 2006, Chicago. Abstract #31.
- Zweben A, Gastfriend DR, Loewy J, et al. Participation in counseling and recovery activities during pharmacotherapy with injectable long-acting naltrexone. Presented at AAAP 2005 Annual Meeting and Symposium, Dec. 8-11, 2005, Scottsdale, Ariz. Abstract #19.
Supported by an educational grant from Alkermes, Inc., and Cephalon, Inc.
