The Complexities of Treating Alcoholism

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March 31, 2000 (Atlanta) -- The drinking often starts when they are young, age 14 or 15. By the time they hit 20, they are showing signs of dependency: they miss work, have legal and money problems, and earn too many traffic tickets. By the time they reach 40, they are looking for help.

"You're talking about people who have over-relied on alcohol for decades to manage anger, loneliness, shyness, conflict, all the stuff of life, and they really haven't gotten their skills up in a lot of areas. It's a very progressive disorder," Barbara Mason, PhD, tells WebMD. Mason is a professor of psychiatry and behavioral sciences and director of the substance abuse division at the University of Miami.

The origins of alcoholism have long been debated. "Even ancient peoples thought about alcoholism as a disease, as opposed to a behavioral or moral problem," says Karen Drexler, MD, an addiction psychiatrist and assistant professor of psychiatry/behavioral sciences at Emory University Health Sciences Center in Atlanta.

"I think the difficulty in understanding alcoholism as a disease is that most of us are able to drink alcohol and not become addicted to it. It makes it a conundrum for those who have not been addicted to understand," Drexler tells WebMD.

About 90% of Americans drink some alcohol; between 15% and 25% can become addicted at some point of their lives. The risk is higher if alcoholism runs in your family, says Drexler. "There's very active research going on to understand what genes contribute to the risk. There have been a couple of candidates that haven't been borne out, but I think in the next few years we will know."

Researchers have identified a gene that controls production of aldehyde dehydrogenase, an enzyme that processes alcohol. If you inherit a gene that doesn't function correctly, the alcohol by-product acetaldehyde is not fully broken down and builds up in the system. "It makes you feel really sick," Drexler says.

Antabuse, the long-time alcoholism treatment drug, works on the same principle. By blocking alcohol's metabolism, it causes serious reactions: shaking, vomiting, and sweating.

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"Antabuse works very well, if you take it," Drexler says. However, Antabuse has never been a cure-all. Many people with liver and heart disease can't take it; others are afraid of the intense reactions it causes. "I have a whole case series of patients who say that Antabuse has saved their lives, but I have more who have been afraid to take it," Drexler says.

Because alcohol acts on the brain's reward pathways, the amount consumed also controls the disease's development, Drexler says. "So even if you don't have a strong family history of alcoholism, if you drink heavily, you can develop it. We know that alcohol, like other addicting processes, acts on this reward pathway, activates it in an artificial and more powerful way than natural rewards do, like food, love, accomplishments."

Newer medications -- Revia (naltrezone) and acamprosate -- act on neurotransmitters that control reward pathways in the brain.

"Naltrexone blocks the opioid receptors; it's a deterrent and a little less frightening than Antabuse. Acamprosate acts on a completely different brain system, acting to normalize the system rather than blocking it," says Mason. "It's the irritability of that system that triggers the relapse. Alcohol quiets the system; it's the absence of alcohol that triggers the irritability and hyperactivity, the unpleasant sensations [that occur during withdrawal] and lead to relapse."

"However, both naltrexone and acamprosate are not panaceas, they're not silver bullets, they don't work for everyone," Mason says.

Alcoholism can be compared to other chronic illnesses like diabetes, which has a strong behavioral component in its development -- and which demands serious lifestyle changes. "In some ways, we're a little more pessimistic than we should be, when we think about what we're asking [alcoholics] to do for treatment of their alcoholism," says Drexler. "It's very similar, the rates of compliance in diabetes with diet and foot care, things that take a fair amount of discipline and continuing motivation. It's about the same as with staying completely abstinent from alcohol."

Behavioral therapy, including the Alcoholics Anonymous 12-step program, helps people to get past denial, understand their behavior patterns, and develop new ways to stay sober. And while behavioral therapists have tried to develop different treatment methods, Mason says one large study showed that the type of therapy made no difference. "As long as you just delivered good-quality intervention, it didn't matter whether it was 12-step or cognitive behavioral therapy. Treatment works!"

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With few inpatient detoxification programs available anymore, drinkers are exposed to alcohol all the time -- a hard battle for many, says Mason. "The fact that we're identifying medications that make a difference, even a modest difference, and we're developing behavioral therapies very specific to alcohol ? there's a combination giving us a lot of hope for outpatient management of a real public health problem."

Newer drugs, and better combinations of drugs, are being developed, Mason tells WebMD. "I think we'll move even further forward to find better drugs? that involve a lot more pathways in the brain. In this disorder, which is so lethal, any advantage is a true advantage, and especially if there is no downside in terms of adverse events or interactions with other substances."

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