Alcohol Use Disorders in Medical Settings

Many health problems or mental disorders that healthcare practitioners (particularly those in primary care) encounter in their everyday practices derive from or are complicated by alcohol use disorders (AUDs). Consequently, healthcare practitioners are in key positions to manage the care of large numbers of individuals with AUDs. However, only a small percentage of these patients are actually treated for AUDs in these settings.

The U.S. Food and Drug Administration (FDA) has approved four medications to treat AUDs. These medications make treatment in primary care and other general medical settings a viable adjunct or alternative to specialty care, with many potential advantages. The consensus panel for this Treatment Improvement Protocol (TIP) believes that direct intervention by healthcare practitioners to treat AUDs is both possible and practical.

Screening for and providing brief interventions to treat AUDs in general medical settings promote healthy life choices and increase the likelihood of recovery, especially for patients who have not yet progressed to chronic alcohol dependence, those with comorbid medical disorders being treated in these settings, and those who otherwise would not seek or receive treatment for their AUDs. Interventions in primary care provide an opportunity to educate and motivate patients who are alcohol dependent and need long-term care to consider a specialty substance abuse treatment program.

From the patient's viewpoint, initiating treatment in a healthcare practitioner's office may be more acceptable than entering a specialty substance abuse treatment program. Perceived or actual barriers to these programs, such as stigma, cost, employment concerns, lack of family or social support, misunderstandings about the nature of treatment, and lack of program availability, discourage many patients from seeking specialty treatment for AUDs. In fact, the number of persons with alcohol or substance use disorders who received treatment at a private doctor's office increased from 254,000 in 2005 to 422,000 in 2006 (Office of Applied Studies, 2007).

Initiating treatment in a physician's office offers advantages for these patients:

• Screening, diagnosis, and treatment of AUDs can increase patient motivation and cooperation (versus the effect of delays between screening, diagnosis, and treatment when patients are referred to specialty programs).
• Integration of treatment for AUDs with that for comorbid medical disorders may increase the likelihood of adherence to treatment and overall patient recovery.
• Familiarity with the primary care setting and “mainstream” methods (e.g., medical management) to treat AUDs reduces the stigma surrounding AUDs.
• The ongoing relationship a patient has with a healthcare practitioner may make referral to specialty substance abuse care more acceptable to a patient.

Helping patients with AUDs can be gratifying; few interventions in medicine can lead to such substantial improvement in individual and public health. This TIP provides a resource to assist the healthcare provider in this effort.

Audience for TIP 49

The intended audience for this TIP includes physicians and other healthcare practitioners who can prescribe and administer medications for AUDs, in either specialty substance abuse treatment programs or healthcare settings such as primary care physicians' offices. Other addiction professionals (e.g., counselors) who want to understand how these medications work and to review the recommended guidelines for medication-assisted treatment of AUDs also will find the book useful.

Recognition of Alcohol Dependence as a Chronic Illness

Research has clarified the strong similarity between substance dependence and other chronic illnesses (e.g., asthma, diabetes, hypertension) for which primary care physician-administered pharmacotherapy and medical management are routine practices (reviewed by McLellan, Lewis, O'Brien, & Kleber, 2000, p. 1693). Genetics, personal choice, and environmental factors contribute to both substance dependence and other illnesses. Research into the pathophysiologic effects of alcohol and drugs—including enduring and possibly permanent neurophysiologic changes—provides further evidence that substance dependence is a chronic illness. By addressing AUDs in their practices, healthcare practitioners also address the source of substantial risk for many other health problems in their patients (see Why Use Medications To Treat Alcohol Dependence? below).

Purpose of TIP 49

This TIP provides clinical guidelines for the proper use of medications in the treatment of AUDs. The underlying objective is to expand access to information about the effective use of these medications, not only in specialty substance abuse treatment programs but also in physicians' offices and other general medical care settings. Members of the Clinical Research Roundtable of the Institute of Medicine have identified failure to disseminate information about and implement new therapies proven effective in clinical trials as a principal roadblock to healthcare improvement in the United States (Crowley et al., 2004). TIP 49 addresses this problem for the pharmacotherapy of AUDs.

What TIP 49 Does Not Cover

This TIP assumes that a patient's healthcare practitioner is acquainted with screening and diagnostic procedures, the patient has a diagnosed AUD, and the patient has gone through (or has not needed) detoxification. Therefore, the following information about treating AUDs is not covered in this TIP:

• Screening and diagnostic assessment for AUDs. The reader can refer to Helping Patients Who Drink Too Much: A Clinician's Guide (NIAAA, 2006), available at http://www.niaaa.nih.gov. NIAAA's A Pocket Guide for Alcohol Screening and Brief Intervention is in Appendix B of this TIP.
• Detoxification and methods to deal with initial withdrawal symptoms. This information is covered in TIP 45, Detoxification and Substance Abuse Treatment (CSAT, 2006a). Excerpts from the Quick Guide based on TIP 45 are in Appendix C of this TIP.
• Medical conditions associated with excessive alcohol use such as cirrhosis. Treatment for these disorders is covered in resources from NIAAA (http://www.niaaa.nih.gov/Publications/AlcoholResearch).

Specialty Treatment Versus Screening and Brief Intervention

Treatment of AUDs can be viewed as continuum-of-care options that include choices of treatment settings, types and levels of treatment services, and medications. Services may range from screening and brief intervention to specialty treatment, with numerous levels of care in between. Primary care practitioners can provide screening, brief interventions, and medical management for many patients who have AUDs or are at risk for alcohol-related disorders but are not receiving care.

Decisions about care level, setting, and type of treatment should be based on patient assessment and commitment to change, as well as treatment availability. For example, the most appropriate patients for brief interventions in a physician's office—and the least appropriate for long-term treatment in a substance abuse treatment program—are those whose drinking exceeds what is recommended, but who are not dependent (NIAAA, 2006).

Why Use Medications To Treat Alcohol Dependence?

When implemented according to recommended guidelines, medication-assisted treatment combined with brief intervention or more intensive levels of nonpharmacologic treatment can do the following:

• Reduce postacute withdrawal symptoms that can lead to a return to drinking (e.g., acamprosate's hypothesized mechanisms of action)
• Lessen craving and urges to drink or use drugs (e.g., naltrexone)
• Decrease impulsive or situational use of alcohol (e.g., disulfiram).

In addition, maintaining a therapeutic alliance with a healthcare practitioner can achieve the following:

• Improve patients' attitudes toward change
• Enhance motivation
• Facilitate treatment adherence, including participation in specialty substance abuse care and support groups.

The Collaborative Study on the Genetics of Alcoholism indicates a genetic link between how an individual experiences alcohol and his or her susceptibility to an AUD (reviewed by Edenberg, 2002). Risk of chronic AUDs appears higher for people with certain genetic variants. Further identification of these genes may lead to new medications for treating AUDs that can help repair, alter, or disrupt alcohol's negative effects.

According to a recent review, chronic heavy drinking can cause long-lasting changes in brain cell receptors and other types of neuroadaptations (Oscar-Berman & Marinkovic, 2003). These neuroadaptations are linked with cognitive and behavioral changes, resulting in the need to drink more to ward off craving and symptoms of withdrawal. Studies reviewed by Hoffman and colleagues (2000) found that neuroadaptations related to symptoms of withdrawal and persistent craving may trigger relapse even after prolonged abstinence.

Pharmacotherapy has revolutionized the treatments of brain-based disorders, including mental disorders such as depression, and treatments for these disorders are increasingly provided by healthcare practitioners. Making such treatments available in general medical settings can improve continuity and accessibility of care. Expansion in treatment settings is underway in opioid addiction treatment. Although most opioid addiction treatment is provided in specialty programs (i.e., methadone treatment clinics), the growing use of buprenorphine by physicians in office-based settings is increasing access to treatments. The widespread use of bupropion in primary care settings for smoking cessation is another example of how the boundaries of addiction treatment have expanded.

Medication-assisted treatment of AUDs is consistent with treatment of other chronic disorders such as diabetes or hypertension. Long-term, perhaps indefinite, use of medication for patient stabilization is reasonable. Medication for AUDs may be employed indefinitely or intermittently along with interventions aimed at changing lifestyle practices to sustain recovery.

Research into alcohol dependence and treatment has shown that integrating brief intervention and counseling and an appropriate medication can have a synergistic or additive effect and improve treatment outcome. Medication can reduce the cravings that disrupt recovery. When cravings are decreased, counseling is more likely to strengthen the individual's coping resources, which are necessary to promote medication adherence and behavioral change. Summaries of research findings have highlighted the following beneficial effects of medication-assisted treatment for AUDs (Garbutt, West, Carey, Lohr, & Crews, 1999; Kranzler & Van Kirk, 2001; O'Malley & Kosten, 2006):

• Lengthens periods of abstinence, which in turn can increase individual coping capacities necessary for long-term recovery
• Prevents a lapse from becoming a full-blown relapse
• Allows brain cells to readapt to a normal nonalcoholic state, helping patients stabilize, think more clearly, have more positive emotional responses, strengthen coping mechanisms, enhance self-esteem, and increase motivational readiness for change
• Relieves symptoms of protracted withdrawal (a hypothesized mechanism of action of acamprosate)
• Supports the effects of psychosocial treatment and sustains the gains of intervention.

The consensus panel for this TIP believes that providing brief interventions (including pharmacotherapy) for AUDs in physicians' offices and general medical settings is a reasonable, practical, and desirable trend that should be greatly expanded. The panel also recommends that screening and periodic reassessment of all patients for AUDs should become regular parts of patient management in primary care and general medical practices because the problem has been shown to be more widespread than many primary care practitioners have realized. At a minimum, patients diagnosed with health problems often associated with AUDs should receive alcohol disorder screening.

Format, Approach, and Organization of TIP 49

The format and approach used in this TIP differ substantially from those used in other TIPs:

• Most of the evidence base for medication-assisted treatment for AUDs is not included in this TIP. Those who wish to review the research base can access the annotated bibliography and literature review via the Internet at http://www.kap.samhsa.gov. The online bibliography and literature review will be updated every 6 months for 5 years after publication of TIP 49.
• TIP 49 focuses on how-to information about medication-assisted treatment for AUDs. Coverage is limited to what the audience needs to understand to use these medications to improve treatment outcomes.
• Increased use of quick-reference tools such as tables and lists in lieu of extensive text discussion makes the information readily accessible and useful for physicians and other practitioners.

Practical information and guidelines for treating patients with acamprosate, disulfiram, oral naltrexone, or extended-release injectable naltrexone are presented in Chapters 2 through 5, respectively. Each chapter follows a template: general description of the medication, rationale for its use, how to use it, which patients are most appropriate for the medication, and clinical advice.

Chapter 6 covers practical information about patient management during pharmacotherapy that applies to all four FDA-approved medications for AUDs, including how to do the following:

• Integrate pharmacotherapy for AUDs into clinical settings
• Assess appropriateness of medications for patients with AUDs
• Choose AUD medications
• Choose psychosocial interventions
• Develop and adjust treatment plans
• Educate patients about pharmacotherapy for AUDs
• Monitor patient progress in medication treatment
• Discontinue AUD medications.

Appendices include the following:

• Bibliography (Appendix A)
• NIAAA's A Pocket Guide for Alcohol Screening and Brief Intervention (Appendix B)
• Excerpts from the Quick Guide for Clinicians Based on TIP 45, Detoxification and Substance Abuse Treatment (Appendix C)
• Excerpts from the Quick Guide for Clinicians Based on TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (Appendix D)
• Lists of the TIP's resource panelists and field reviewers (Appendices E and F, respectively).