Rethinking the Approach to Alcohol Abuse
From the American Psychiatric Association
TORONTO—Research into alcohol abuse and its consequences is charting new directions for the diagnosis, treatment, and prevention of alcohol abuse, now termed alcohol use disorders by psychiatrists, reported experts at the 159th Annual Meeting of the American Psychiatric Association.
Alcohol is the substance most frequently reported in all substance abuse treatment centers, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Nearly 18 million persons in the United States suffer from alcohol-related disorders, and 8% of them are classified as alcohol dependent.
Alcohol-related costs in the United States are currently estimated at $185 billion annually.
“Alcohol use disorders are the most prevalent psychiatric disorders in the United States,” said Frederick Stinson, PhD, of the NIAAA, Rockville, Md, noting that an analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions - a nationally representative study of 43,093 adults aged ≥18 years-revealed prevalences of alcohol abuse and dependence of 4.65% and 3.81%, respectively. Risk factors were male gender, Native American ethnicity, young age, never having married, and living in the Midwest.
Diagnostic Criteria
Alcohol dependence is widely underdiagnosed because of denial, stigma, and common comorbid disorders, including anxiety, depression, diabetes, hypertension, and hepatic disease, according to Kathleen Brady, MD, of the Medical University of South Carolina, Charleston.
The criteria for the diagnosis of alcohol dependence (but not alcohol abuse) are listed in Table 1.
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In a 10-year prospective study of 514 men and women, conducted by Deborah Hasin, PhD, Columbia University, New York City, and colleagues, significant predictors of new-onset alcohol dependence were a family history of alcoholism, low level of response to alcohol, young age, and ≥5 drinks per occasion ( <.03).
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Significant predictors of new-onset alcohol abuse were male gender, smoking, and heavy drinking episodes ( <.03). Almost all cases of alcohol abuse were diagnosed in individuals who were driving after drinking excessively.
About 30% of American adults drink at levels that elevate their risk for physical, mental, and social problems, according to the NIAAA. Men who drink ≥5/day standard drinks or ≥15/week, and women who drink ≥4/day or ≥8/week are at increased risk for alcohol-related problems (Table 2).
Screening in Primary Care
The primary care office provides an excellent setting for screening for alcohol problems, particularly because of the link between alcohol abuse and comorbidities frequently seen in outpatient settings.
The NIAAA recently revised its clinician’s guide, “Helping Patients Who Drink Too Much” (available at www.niaaa.nih.gov).
An important change is that initial screening for alcohol use disorders has been streamlined to a single question—“Do you sometimes drink alcoholic beverages?”
Disialotransferrin (DST), a carbohydrate-deficient transferrin isoform, may be a useful biomarker of alcohol misuse and dependence, said Raymund Schwan, PhD, of the University Hospital, Clermont-Ferrnad, France. He and his colleagues studied asialotransferrin and DST levels in 85 alcohol-abusing and 82 alcohol-dependent persons and a control group of 88 moderate drinkers.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
Asialotransferrin demonstrated a sensitivity of 34% and a specificity of 100% for detecting alcohol abuse; sensitivity increased to 57% in alcohol-dependent persons. DST levels distinguished moderate drinkers from alcohol-dependent persons with a sensitivity of 85% and a specificity of 97%. The investigators suggest it may be useful to combine DST levels and , criteria for diagnosis and differentiation of alcohol abuse.
Pharmacotherapy
Only about 20% of individuals with significant alcohol-related problems are identified, and of those, only about 20% receive treatment, said Hugh Myrick, MD, of the Medical University of South Carolina, Charleston. Drug therapy is used in about 1% of those who receive any treatment.
Current drug treatment options include disulfiram (Antabuse), acamprosate (Campral), and naltrexone (Revia).
Naltrexone
. “An exciting development is recent evidence that the response to naltrexone is great among alcoholics with high alcohol craving and a family history of alcoholism,” says Helen Pettinati, PhD, of the University of Pennsylvania Health System, Philadelphia.
JAMA
Patient lack of adherence is a major problem with this drug, Dr Pettinati said. An extended-release oral formulation of naltrexone and a long-acting naltrexone preparation that delivers therapeutic drug levels for 30 days after a single injection are now in development (.?2005;293:1617-1625).
Acamprosate
has been associated with greater rates of complete abstinence, longer times to first drink, and more abstinent days compared with placebo, said Robert Swift, MD, Brown University Medical School, Providence, RI. Compliance rates in patients treated with acamprosate are typically >85%. This agent significantly increases the chances that a relapsed patient will be able to return to a period of complete abstinence.
Anticonvulsant agents
, including topiramate (Topamax), gabapentin (Neurontin), and valproate (Depakote), are proving useful as antiwithdrawal and/or relapse prevention therapy in patients with alcohol dependence, said Bankole Johnson, MD, of the University of Texas Health Science Center, San Antonio. He said that anticonvulsants may ameliorate the symptoms of alcohol withdrawal and prevent relapse by antagonizing glutamate and facilitating gamma-aminobutyric acid activity within the cortico-mesolimbic system.
Topiramate
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may antagonize alcohol reward—or the perceived benefit or pleasure associated with drinking—and thereby decrease the risk of alcohol abuse by inhibiting mesocorticolimbic dopamine release. In a double-blind, controlled trial of 150 alcohol-dependent patients randomized to 12 weeks of topiramate or placebo, those who received topiramate had 27.6% fewer heavy drinking days ( = .0003), greater overall life satisfaction ( = .01), and fewer harmful drinking consequences ( = .007).
Quetiapine
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(Seroquel), an atypical psychotropic agent structurally related to clozapine, may also be useful for the treatment of alcohol dependence, said Kyle Kampman, MD, of the University of Pennsylvania Health System. In a controlled clinical trial conducted by him and his colleagues, 61 alcohol-dependent patients were randomized to quetiapine 400 mg or placebo daily for 12 weeks following detoxification. Compared with the placebo group, the quetiapine group had significantly less alcohol use ( = .03) and heavy drinking ( = .01). Complete abstinence was achieved by 31% of the quetiapine group versus 6% of the placebo group ( = .012). Quetiapine was well tolerated, and there were no medication-related serious adverse events.
The selective 5-hydroxytryptamine3 receptor antagonist ondansetron (Zofran) appears to be effective in alcohol-dependent adults with a familial or biologic predisposition who have begun drinking in their youth, Dr Johnson said.
Evidence is emerging that serotonin reuptake inhibitors may be useful in alcohol-dependent patients who develop the disease as adults and who have little or no familial disease predisposition.
KEY POINTS
Alcohol-related disorders are the most common psychiatric disorders in this country, affecting nearly 18 million Americans.
Denial, stigma, and common comorbidities explain the dismal rate of diagnosis of alcoholism, currently at about 20%.
The primary care office is a natural setting for initial screening of alcohol abuse, using the question-“Do you sometimes drink alcoholic beverages?”
Emerging evidence suggests that available drug options can help patients abstain from alcohol, and new drugs are in development.
