man's arm on a bar by beer taps, glasses

Issues and trends

Bridging the great divide

The challenge to integrate drug therapy with psychosocial treatment

By Kim Goggins

Throughout high school, John* drank heavily. In college, he discovered that he could avoid his “morning-after” hangover by continuing to drink. Soon he was drinking every day, all day. “I drank a big bottle daily,” he says. “I kept it in my car so I could drink at whatever job I had.” John tried to quit drinking without help many times, but when he did, he experienced hallucinations and had been hospitalized for severe withdrawal symptoms. John is now getting treatment – a regimen of cognitive-behavioural therapy, boosted by a medication that keeps his cravings at bay.

He isn’t alone. According to the 2004 Canadian Addiction Survey by the Canadian Centre on Substance Abuse, nearly 80 per cent of Canadians aged 15 and older drink alcohol. Although most do so moderately, 17 per cent are considered to be high-risk drinkers, according to the World Health Organization. A 2008 study by the Centre for Addiction and Mental Health (CAMH) in Toronto revealed that alcohol dependence costs each Canadian $463 per year and that the direct health care costs exceed those of cancer.

Recognized as a chronic brain disease, alcohol dependence is characterized by long-term, often permanent changes in the neuron-chemical properties of the brain. New knowledge from neuroscience research is helping develop pharmacologic treatments that act on brain mechanisms involved in alcohol dependence. These medications target immediate concerns like cravings and withdrawal, and can keep these in check in the long term, which is important for a disorder characterized by high rates of relapse.

In the meantime, psychosocial treatments and recovery supports like cognitive-behavioural therapy (CBT) and Alcoholics Anonymous (AA) have long been the mainstay for dealing with alcohol dependence. In fact, there has traditionally been a divide between pharmacologic and psychosocial approaches to treatment and recovery, a divide that is being challenged by studies and clinical experience that suggest that combined treatment is the most effective approach.

In Canada, three drugs have been approved for treating alcohol dependence. The recently approved drug acamprosate (Campral) blocks the rewards of alcohol and relieves withdrawal symptoms such as tremors, insomnia and anxiety. It joins naltrexone (ReVia), which reduces the rewarding effects of alcohol, thus reducing cravings. Disulfiram (Antabuse) is a deterrent that has been available for decades, but its availability is now limited due to the severe and sometimes dangerous reaction that occurs when alcohol is ingested.

Although these medications can help to promote abstinence or reduce drinking, some clinicians lament that they are not prescribed enough. “It’s dismal; medications are under prescribed,” says Dr. Peter Selby, clinical director of Addiction Programs at CAMH. He cites societal attitudes towards alcohol dependence and a lack of physicians trained in addiction as reasons.

Misconceptions about pharmacotherapy by non-prescribing clinicians and clients are also to blame, says Selby: “Some clinicians and clients think that medication and counselling can’t go together or that it will somehow not make the recovery real,” he says. “This means that many people continue to suffer longer and harder than they have to, not because of lack of science, but because of a lack of knowledge translation of that science into practice and policies.”

What that science says is that combining psychosocial and pharmacologic treatments and support optimizes recovery. Dr. Juan Negrete, an addiction psychiatrist and professor of psychiatry at McGill University in Montreal, believes that nonpharmacologic interventions, such as motivation enhancement therapy, CBT and AA, should also be used to treat alcohol dependence and provide support (see sidebar).“Medication can be taken without psychosocial therapy, but that isn’t advisable,” he says. “Individuals who have stopped drinking need to reshape their living style and gain understanding and control of their behaviour, define their goals and deal in a different way with psychological and emotional issues. For that you need therapy.”

Results from the U.S. Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study, which were released in 2006, show that individuals who received naltrexone and specialized alcohol counselling, along with medical management by a health care professional, had the best drinking outcomes after 16 weeks of outpatient treatment. Although counselling alone was effective, of the 1,383 people with alcohol dependence who participated in the study, those who received medication, counselling and medical management did much better than those who received placebo and counselling.

Pharmacotherapy of a sort is not new to the psychosocial approach, says David North, executive director of TriCounty Addiction Services in Smiths Falls, Ontario. He points out that many clients already use caffeine and nicotine to self-medicate; counsellors recommend over-the-counter herbal remedies or dietary supplements to help curb withdrawal symptoms; and historically, Antabuse and methadone have been accepted aids to addiction treatment. “The metaphor prescription is already common in the business,” says North. “It’s the nature of the drugs that changes, but it’s the psychiatrists and doctors who prescribe, whereas the rest of us can’t.”

It’s here that challenges emerge, as front-line addiction professionals must make referrals to prescribing physicians who usually do not have the same level of addictions training or the time to provide ongoing care to clients.

“Because you now have power and control over a particular treatment methodology, access involves a variety of rituals – referral, assessment, consultation – and some of them don’t involve the client, per se,” says North. “From a psychosocial perspective, we try to empower and enhance self-direction on the part of the client. Any time you introduce a new power struggle in which the client may not be involved, you restrict access to clients getting to learn about that kind of empowerment.”

Even if prescribing and non-prescribing clinicians worked more closely together – a concept that North supports – it’s unlikely that provincial governments will increase funding to cover the cost of medications or enable addiction treatment centres to hire physicians for their programs. In fact, the vast majority of community-based treatment centres in Canada and the U.S. do not have a prescribing physician or psychiatrist on staff.

Lack of training in pharmacotherapy among addiction counsellors and a philosophy that can conflict with complete abstinence can also be barriers, points out Christopher Shea, clinical director at Father Martin’s Ashley, a residential and addiction treatment centre in Havre de Grace, Maryland. “Most physicians aren’t educated in chemical dependency and addiction,” he says. “Two professionals are trying to collaborate, but in most cases, neither has a good idea what the other does. If the counsellor can understand why the medication is being prescribed, then the physician can explain to the patient, ‘This is the reason we are prescribing this medication and these are the side-effects.’ The non-prescribing clinician can then follow up with the patient by talking about how the medication will curb cravings. That approach will enhance treatment and recovery.”

Communication is another key factor, says Catherine Hardman, executive director of Choices for Change Alcohol, Drug and Gambling Counselling Centre in Stratford, Ontario. “Each professional needs to respect the other’s expertise and see that person as a partner in working with the client to ensure good treatment,” she says. “In the future I hope to see a closer relationship between the systems, with respect for each discipline. Both [prescribing and non-prescribing clinicians] have a lot to offer, and if we are serious about good client care, this needs to happen in all aspects of the health care system – more integration and understanding of what we do and can offer each other and our clients.

*not his real name

Psychosocial approaches to treatment and recovery

Numerous treatment approaches for alcohol dependence are well established, widely available and effective. Here is a sample:

Withdrawal Management, also known as alcohol detoxification, is the process of ridding the body of alcohol while safely controlling and managing withdrawal symptoms. This is done under medical supervision, often in a residential setting, and may be the first step in treatment.

Cognitive-Behavioural Therapy (CBT) takes a structured, problem-solving approach based on the cognitive model of emotional response. Focusing on the present, therapists help clients think differently about their current situation and as a result, to feel and react differently.

Motivation Enhancement Therapy (MET) uses motivational strategies to activate the client’s own change resources. Therapists provide feedback on the risks or damage associated with the alcohol use, while emphasizing the client’s personal responsibility for change. The client is advised how to make healthy changes and is given alternative change options.

Alcoholics Anonymous (AA) is a mutual support program that is based on 12 steps required for recovery and sobriety (see pp. 10–11). AA is considered to be a support rather than treatment; as such, clinicians recommend that AA works best when combined with drug or psychosocial therapy.

Adapted from www.alcohol-treatment-info.com/About_Us.html

The million-dollar question

“When was the last time you had more than five drinks (if male, four if female) in one day?” That’s the single question that studies have found to be an effective screening tool that opens the door for clinicians to discuss a client’s problematic drinking. Brief Interventions Brief but effective screening tools are crucial to detecting and treating alcohol problems, given that only one in three people with alcohol problems seek treatment, according to a 2003 study by the Centre for Addiction and Mental Health (CAMH) in Toronto. More than 34 randomized controlled trials in the United States have found that alcohol screening and brief interventions are effective in decreasing consumption in people with problematic drinking. These brief interventions usually involve counselling in five or fewer standard office visits. The meetings involve providing straightforward information about the negative costs of alcohol use and practical advice on how to reduce or stop drinking.

Front-line professionals, particularly those working in primary care, such as a family doctor or nurse, are well-positioned to detect problems because they are often the first point of contact and may have an established relationship with patients. Primary care providers are also important on the continuum of care because once treatment is finished with another provider, they play a key role in recovery and relapse prevention.

It may not be realistic to expect a busy physician to take more than 10 minutes with a patient, but even acknowledging the problem with the patient is beneficial, and nursing staff can follow up, notes Montreal addiction psychiatrist Dr. Juan Negrete. “What happens with many alcoholics is that the first professional contact they have is with a general physician,” says Negrete. “The short intervention could be for that doctor to notice the problem, to identify it and to simply tell the patient, ‘You cannot carry on. You must do something about this.’ Even if the doctor doesn’t do anything else, in many cases, that itself has a positive effect.”

Family health teams have a promising role to play in screening, treatment and referral, but so far, most have difficulty providing this sort of service, according to Dr. Peter Selby, clinical director of Addiction Programs at CAMH. He says that inadequate training and the lack of appropriate remuneration and practice standards within these emerging models of care must be addressed: “We have to educate teams about how effective they can be using brief interventions and medications to treat alcohol dependence,” he says. He adds that we need to leverage the skills of all members of the interprofessional team and apply incentive models to facilitate these changes, much like has been done to promote the management of diseases like diabetes.